Aneet Kapoor, Greater Manchester LPC chair, provided the Pharmacy Show with a stand out moment, with an engagingly frank assessment of the new contractual framework. Here's the highlights...
I don’t think there’s a surprise in there, personally. If we cast our minds back to the week before Christmas 2015, and the lovely letter from the Government, outlining what they wanted from community pharmacy on the back of a load of cuts, a lot of it was in there. We were blinded by the first few pages that talked about cuts.
No-one’s to blame. I’m a contractor, I’m the same. I never really looked at the back part of it. And when the contractual framework came out, not much had changed.
It’s not going to be easy. We used to have local enhanced services. The morning after pill, stop smoking services. It was fun having services commissioned, and it was dead easy as an LPC and as a contractor, because they were commissioned by one body, the primary care trust. Along came Andrew Lansley. We started seeing our services fragment, with multiple commissioners – local authorities, CCGs, NHS England – making our environment more complex.
A typical single locality pharmacy with one CCG and one local authority might have local enhanced services (LES) commissioned by an NHS England local office, CCG contracted services using the NHS Standard Contract, a Pharmacy Integration Fund service using a LES commissioned service, local authority public health services, an LPC explorer service, an NHS Foundation Trust service, a sub-prime provider service, all using local contracts, an LPC provider company service as part of a contracting suite, and private services developed by the owner.
Take one example – sexual health. NHS England wants a service from community pharmacy, but it doesn’t commission it. Every single locality is going to have a different set up for commissioning that service.
MURs have been the backbone of advanced services for 14 years and we will see the end of them in 2020. Are we surprised? No. Is community pharmacy unhappy about it? Yes. But only 64 per cent were engaging with it. There was money we weren’t using effectively. There wasn’t much of a conversation community pharmacy nationally could have about it.
But they need new services around urgent care. It’s going to underpin everything going forward. If we don’t get this right, you can forget the bits behind and underneath it. We need to get that stuff right before we think about long term conditions. We are going to have to say ‘yes, we can deliver this’, and then we will be able to kick on to deliver more clinical services providing value to our patients and the NHS.
We begrudge the term ‘clinical pharmacist’ because it divided us, but in my view community pharmacy failed to plug a gap around medicines safety and optimisation, both on the ground and nationally. The 2005 contract was intended to propel us into delivering extended services in medicines safety and optimisation roles. They never came. That’s how I see it. Under primary care networks there are roles for pharmacists. These can quite easily be community pharmacists; it’s down to us to embrace that role and start to plug the gap we didn’t fill in the past.
In Greater Manchester, under devolution in 2015/16 they set up neighbourhoods of 30-50,000 to deliver ‘out of hospital care’. Those leading the neighbourhoods were not mandated to engage with the whole of primary care. That was us banging on doors, showcasing what pharmacy could do to help them deliver on their priorities. The beauty of PCNs is that we have a hook. They are mandated to engage with primary care – we are primary care and we can provide that port of call for them.
The value of dispensing is going to go down. Items should no longer be our sole focus; they bring patients to us. But if we do not focus our attention on the delivery of local services, especially those commissioned by the NHS, then dispensing income will fall, there will be no service income to replace it, and if enough of us ignore it, services will be withdrawn, and Amazon will win. There’s only one chance to succeed, to ensure we get those services to deliver our futures as community pharmacy. Contractors say ‘yeah, but when it comes to our FP34, services only make up a small amount, it’s all on dispensing’. Maybe 10 years ago. Not any more.
I’m an owner and we are heading into the red. There are months where we’ve made a loss after we take out all our costs of dispensing. We can’t control branded generics and duration of prescribing driving down income, but then we are also leaving money on the table. We can’t influence the prescribing, but we can influence local services. We know better than the GPs what the needs are within our local population because we see these people every single day. We need to articulate how we deliver services to those patients to meet those needs.
Somebody challenged me last week about an inhaler service in GM: £17 a review. They told me they don’t have the time. My challenge back was: ‘tell me how many prescriptions you need to dispense to make £17 profit?’ It’s a mindset, thinking about what is of value going forward.
I can safely say I don’t need to go anywhere near 60 per cent of the prescriptions coming through my pharmacies
Two thousand years ago, Aristotle came to the unsurprising conclusion that what a person wants above all is to be happy. In 1961, a Hungarian-American named Mike [the psychologist Mihaly Csikszentmihalyi] called it ‘flow’. When team members are in the flow, they are intensely focused on an activity, that is of their own choosing, that is neither under-challenging, not over-challenging, has a clear objective, that receives immediate feedback.
Apply that to community pharmacy. Prescriptions are a ‘bore out’ activity. Under-challenging. Compare that to NMS – focused activity, clear objectives, immediate feedback. Ticks all the boxes for me, yet in GM last year we left nearly £3m on the table when it came to NMS.
As pharmacists, we need to think about what bore out background work we need to remove ourselves from to ensure we can deliver services. I can safely say I don’t need to go anywhere near 60 per cent of the prescriptions coming through my pharmacies. I just need to be responsible for them; if anything changes my staff signpost those prescriptions to me and I will review them and update the clinical check on the system. What does that do for me? Frees me up to be able to deliver services.
We need to think about how we are going to make dispensing more efficient. The Government has already outlined its solution: automation. If you are average Joe, like me, and you don’t have loads of money and space, you need to think about sharing resources when it comes to automation. Consultations are out now about allowing hub and spoke dispensing across legal entities. They need to get this right because it is a huge enabler for us to deliver our future.
Tools like Check34 and CheckRx help us benchmark KPIs for dispensing – item numbers, nominations, average item value – that will be of no value to us going forward. Let’s think about what we measure. The huge stands at the Pharmacy Show are wholesalers and drugs. The guys with the solutions to make community pharmacy smarter are tucked away in small corners. Those big stands are not going to fund our futures; the guys with the solutions are.
I am shocked at how many people still don’t use electronic CD registers. This is the kind of thing I’m talking about. Using time efficiently. I’ve been using electronic CD registers for four years. It takes 30 seconds to a minute a day to get them done.
Do you check your endorsements? Are you checking items over £100? Do you check what you’ve submitted and what you are getting paid? We have this massive leaky bucket.
The multinationals have taken big decisions. Around free deliveries. A lot of them are charging for MDS. I put my flu price up this year because the vaccine is costing me more. Yet there are pharmacies out there that will want to go and match Asda and literally do it for nothing.
Are we spending time trying to buy bendroflumethiazide at 10 pence instead of 11, while missing out delivering a flu jab that’s going to give us £15 or an NMS that’s going to give us potentially £20? Are we embracing the skill sets in our teams? Are we measuring them appropriately?
A new service is commissioned, we all start delivering. Two hundred in the first month, second month less than 50. Why? We got consumed back in the bore out, day to day work.
How many days a week are you providing a service? Are you doing it every day, or only Monday and Tuesday? Why? Is there is a skill problem? Is there a resource problem? This is the kind of thing we are not delving down into, to find out what the barriers are to delivering services.
Are we taking our teams with us? Pharmacists feel we have to do everything, but if we use our teams better, we free up capacity for ourselves. Velresco studied 10 pharmacies for the NPA. By concentrating pharmacists on the work only they can do, and delegating much of the rest, an additional 12 per cent of pharmacist time was released as efficiency ‘to do even more’, to engage with more services, or to upskill their team further.
We don’t build on our strengths. We spend too much time thinking about threats and building up our weaknesses. The biggest threat we had was further cuts. That’s gone. We’ve got fixed income. Within that five years we know dispensing services need to transform.
It’s not just me saying this. The last NHS England Board meeting discussed community pharmacy in urgent care, the importance of automation, and how they wanted to see the dispensing model change. Richard Douglas [an associate non-executive board member] highlighted that over an eight-year period they are going to get a whole load more stuff for £200m less. He was concerned that either they had it wrong in the past, they’ve not done the numbers right, or that they could put us under so much pressure it’s going to burst. The response to him was ‘we’ve not given anyone, ever, in the NHS, a five-year deal. It’s unprecedented because the sector needs to transform itself from a supply-led model to a service-led one.’
What happens after that is down to how we perform between now and 2024. Urgent care is the start. We have to get the Community Pharmacist Consultation Service (CPCS) right. Register for it now. Take the £900, and start getting your teams ready.