By Rob Darracott

We’ve heard it often enough. “Why do GPs get a better deal?” or “Why does community pharmacy get better treatment in Scotland?” The Independent Review of Community Pharmacy Contractor Representation and Support sounds a dry read, but in their recommendations Professor David Wright and his team offer some clear solutions to address these gaps, and others that have been a source of frustration for many for years. The case for radical change is laid out in the first 40 pages. It’s a long read, but well worth it.

When he commissioned the review, PSNC chief executive Simon Dukes might have been hoping for, but not expecting the radical redesign Professor Wright sets out. It’s going to require bold, altruistic, imaginative and ambitious leadership across the sector, to implement. Some are going to ‘lose out’ but all should recognise that the impact on any individuals, while difficult, is nothing compared to the needs of the many, especially when the many are the people who pay for it all.

In essence, what’s on offer is a bringing together of national and local representation, with clear accountability and greater transparency across the system. At present, LPCs and PSNC are funded from the levy on NHS remuneration paid to LPCs by the NHS Business Services Agency. As a contractor, you don’t write a cheque, because you never see the money in the first place. It totals £11m a year – around £1,000 a pharmacy. Roughly 70 per cent funds your LPC, and 30 per cent is passed on to the PSNC.

The pandemic has only hastened the reshaping of primary care, and that is happening in spite of pharmacy, rather than with it.

Currently, ‘who is working for who’ is a moot point. He who pays the piper may normally call the tune, but LPCs have for years held little sway over the national executive, if they ever did. The LPC Conference was increasingly stage managed then abandoned as an exercise in populist policy setting. The national negotiating committee itself, constituted by regional elections (often uncontested) for independent representatives and with multiple appointees, was distant. Feedback to the LPCs is done by the elected regional representatives, most of whom performed the role selflessly and seriously, and were good at it, and some of whom didn’t and weren’t (you were better informed by not seeing them in one or two cases).

Professor Wright recommends bringing all that together, and he’s right. He suggests the current balance of interests between independents and multiples is retained in the structures, but with local representative leadership at the centre of the forces for change. In an increasingly localised NHS, that has to be right. The pandemic has only hastened the reshaping of primary care, and that is happening in spite of pharmacy in most cases, rather than with it.

So out goes the PSNC as currently constituted, to be replaced by a Community Pharmacy England Council (CPEC), comprised of the chairs of the LPCs, which should be renamed as Community Pharmacy [Locality] (CP[L]), as some have done already. The Council would be responsible for policy – more later – with the governance of the total system and the overall strategy setting vested in a smaller Board comprised of a mix of national and local pharmacy representatives (a lift from optometry, which has had a similar structure for years). National negotiation, informed by the policy discussions at the Council, and supported by evidence, would be handled by a professionalised and trained negotiating team, built on similar lines to the GPs’ negotiating team. Makes sense to me.

For some community pharmacy contractors, it will be news that representation costs you £1,000 a year on average, which should prompt the question of the value delivered by that investment. A 7 per cent cut in remuneration since 2015, a failed judicial review and appeal (costing how much?), and last in line status during the pandemic.

Some LPCs are doing fantastic work, with local service commissioning, membership of primary care strategy groups and workforce academies. Others are too small, under resourced (even with higher per contractor levy rates) and are a long way from the local action as a result. Annual report? You’re joking – incidentally PSNC only published its first in 2019. Financial statement? You’ll be lucky.

So, why should contractors welcome this review and its recommendations, and be telling their Local Pharmaceutical Committees to get behind it, and push on quickly?

First of all, Professor Wright notes the reactive nature of the contract negotiations in England, with the running largely being made by the payors. There’s criticism of the current system by which the 31 members of the PSNC do all of this, and mark their own homework – I’ve lost count of the number of “best we could achieve” deals the sector has had. It’s easier to make that claim when few knew what you were asking for in the first place.

The solution is a professionalising of the policy making function – that should mean policy professionals doing the work, rather than just pharmacists who think they might be good at it – as directed and decided by the CPE Council which will be, remember, populated by local representatives. With a massive improvement in communications, using the technological lessons of the pandemic, that should mean more opportunity for input, ideas, feedback and progress reporting top to bottom.

Second, the governance framework will apply to all organisations, who will need to sign up to play. This should open up, where it’s needed, the workings of those committees whose current activity remains a mystery to all but those around the table. Proper governance means payments, too, and formal standardised processes for recruitment – no more interviewing in the local for the new chief officer, for example.

The very best LPCs have long moved past that, and should have nothing to fear, but there will be challenges to those committees that have survived for too long on the tremendous enthusiasm and dedication of one or two individuals. In this brave (modern) new world, executives will do, and boards (elected and appointed) will decide and be responsible to those they represent for the outcomes achieved. It’s a radical departure for some, but it’s how lots of organisations, from school boards to trade associations outside pharmacy, actually work.

that should mean policy professionals doing the work, rather than just pharmacists who think they might be good at it

Third, Professor Wright has taken a long hard look at how the doctors, the optometrists, and even Community Pharmacy Scotland, do business. The proposal for the Council and system oversight owes much to Scotland, but his proposal for a trained, supported and paid (two days a week) negotiating team, recruited to a spec from among contractors, is an exciting prospect taken directly from GP-land. There’s much more to this than I have space for here, but the rationale includes psychological and sociological perspectives, as well as a clear link to evidence and business case building – adding the “how” and “why” to the “what”. He also raises a real role for patients too – who better to make the case for pharmacy service development?

Fourth, and imaginatively, the review recommends a Community Pharmacy Integration Centre, to oversee service development and evaluation, which recognising the need for community pharmacy services to be better integrated into NHS systems and clinical pathway. This centre could produce national service specifications, and work with CP[L]s to create new ones, trial them, and support design and analysis of all evaluations. That’s long overdue too (and also based in part of structures that have benefitted optometrists for a few years). We have no idea, right now, which is the best, say, emergency contraception commissioned service. And by best, I mean best for its users as well as pharmacy.

Lastly, I’m delighted to see Professor Wright suggest the NHS should be so interested in seeing a community pharmacy sector that understands what the NHS wants, and which is committed to developing service propositions, testing, evaluating and implementing them as part of an integrated primary care system that is central to NHS development, that it might help to fund the transformation. Change within medicine has long been supported by the public purse. Pharmacy never asks for money for change – I was once told to take a direct appeal for implementation funding out of a consultation response because it would never be met. Madness and arrogance rolled into one.

Professor Wright suggests community pharmacy needs a clear vision and strategy, which takes full account of the context in which it operates now and will operate in the future, and of course it rehearses the importance of pharmacy speaking with a ‘single voice’, as the doctors seem to manage more often than not.

Under the reshaping of representation proposed, there will be more opportunity for people with ideas to contribute to creating the way forward than there has been for a generation. And the terms limits for positions around the table – never popular in any pharmacy organisation – should help ensure that the whole decision-making structure is regularly refreshed too, providing scope for proper succession planning and representation career building.  

The big question remains. Is community pharmacy brave enough to go for this? Independents will be right to be concerned about marginalisation, but there are some great role models among the independent community pharmacy chairs of LPCs out there in the current system. That says to me that many will pick the best person for the job, regardless. There’s work to be done, for sure, but that work starts with the review, the immediate discussions to come, and a proper understanding of the considerable gains to be had from the recommendations.

So, if you want more of a say, better communication, a clear line through to those taking decisions on your behalf, and a better sense of who’s spending your money on what, and why, then this should be a no brainer. But you also need to get on with it. The world is moving on quickly. Those who have got used to more rapid decision making in the face of a virus from the other side of the world, are not going to wait for pharmacy round the corner to make its mind up about how many seats should be around the table and the colour of the carpet.  

You can read the review here.