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Transformation ahead for representation in England?

By Rob Darracott

When he commissioned the review of community pharmacy representation in England, PSNC chief executive Simon Dukes might have been hoping for – but not expecting – the radical redesign Professor David Wright has set out. It’s going to require bold, altruistic, imaginative and ambitious leadership across the sector to implement his independent review. 

Under the plan, some of the individuals who’ve kept things going at the top will be thanked for their service and waved goodbye, in a shakeup of governance that would see the end to ‘seats for life’. At more than £11m a year, and with recent outcomes limited to years of cuts and lost court cases, few would argue that the current system delivers value for money. 

Professor Wright suggests that the professionalising of matters as diverse as policy development, human resources and negotiation will deliver more value for those who pay for it all: contractors. And since the current approach clearly isn’t working…

In essence, he recommends bringing together national and local representation, with clear accountability and greater transparency across the system. At present, LPCs and the PSNC are funded from the levy on NHS remuneration paid to LPCs by the NHS Business Services Agency. It’s around £1,000 a pharmacy; around 70 per cent funds LPCs, with 30 per cent for PSNC. 

there will be more opportunity for people with ideas to represent those that want transformational change

He’s also proposing to resolve the ‘who is working for who’ conundrum by creating a Community Pharmacy England Council (CPEC) comprised of the chairs of the LPCs, which are to be renamed Community Pharmacy [Locality] (CPLs), as some are already. The Council would be responsible for policy, with the governance of the system and overall strategy setting vested in a smaller Board comprised of a mix of national and local pharmacy representatives. This is a lift from optometry’s Local Optical Committee Support Unit (LOCSU), which has had a structure like that for years. 

National negotiation, informed by the policy discussions at the Council, and supported by evidence gathered by a Community Pharmacy Integration Centre, would be handled by an expertly constructed and trained negotiating team, built on similar lines to that of the GPs.

The review recognises the tremendous work being done by some LPCs, but notes that others, often with large geographies and small numbers of contractors, are under-resourced (even when collecting higher per contractor levy rates) and a long way from the local action, as a result. It suggests a smaller number of, on average, larger CPLs (a minimum of 200 contractors is suggested for viability), with back office functions centralised as part of the national support office.   

A move to standard service templates

CPLs would benefit from the availability of standard service templates, and would also gain from the additional investment in policy and communications functions. The governance framework would apply to them too, and Professor Wright says entry to the Council and support would be contingent on CPLs signing up to the plan. 

The very best LPCs have long moved past all that, and should see much to gain from a more connected whole, others will need help. In the brave new world, executives will advise and implement, and boards (elected and appointed) decide and be held accountable for outcomes. It may be a radical departure, but Professor Wright hasn’t had to go far for inspiration. It’s how most organisations work, from school governing bodies to trade associations outside pharmacy. 

Where it works, either through the enthusiasm and determination of individuals over many years of individuals, or through the sort of chief officers that have been appointed in recent years, LPCs are much more attune to the changing context of the NHS than any national organisation can be on its own. Community pharmacy contractors, multiple and independent alike, are benefitting now across the country from commissioned services delivered through a single provider company contract, supported by implementation planning and training from a local academy set up for the purpose.

The new structures have much to learn from these vanguards, and the role of a new cadre of LPC chief officers, often working in tandem with more visionary chairs, must be recognised for the leadership they have shown in getting community pharmacy past talking and into action. They have often been the ones who have created and maintained the relationships on the ground with the GPs, the clinical commissioning groups, the local authorities and now, the primary care networks. That expertise and experience needs to be recognised and valued and available in the new structures. It must not be lost. 

Taking a broader view

The recommendations owe much to Professor Wright and his team’s examination of how doctors, optometrists, even community pharmacists in Scotland, do business. The proposal for the Council and system oversight owes much to Scotland, while that for a trained, supported and paid (two days a week) negotiating team, recruited from among contractors to a design and a rationale that includes psychological and sociological factors, is taken directly from the British Medical Association. 

a new cadre of LPC chief officers must be recognised for the leadership they have shown in getting past talking and into action

The creation of a Community Pharmacy Integration Centre to oversee service development and evaluation at last recognises that community pharmacy services do not exist in a vacuum, and need to be better integrated into NHS systems and clinical pathways. This centre should work with CPLs to produce national service specifications, trial them, and analyse evaluations. It’s also in part based on the structures that have benefitted optometrists for years. Right now, community pharmacy collectively cannot say which emergency contraception or smoking cessation commissioned service is best for patients. Or for community pharmacy.

It’s refreshing to see Professor Wright state that community pharmacy needs to better understand what the NHS wants. It’s also refreshing to see someone suggest that the NHS might help fund the transformation of the sector if it demonstrates that it is on the same page as the NHS. Change within medicine has long been supported by the public purse; pharmacy never asks the question. 

The recommendations are topped off with the suggestion that community pharmacy needs a clear vision and strategy. It goes without saying that Professor Wright expects this whole structure to be single minded in pursuing a strategy to realise the vision, something the sector conspicuously failed to do with 2016’s Community Pharmacy Forward View. 

Under the reshaping of representation proposed, there will be more opportunity for people with ideas to represent those that want transformational change than there has been for a generation. Term limits for seats around the table should help ensure the decision-making structure is regularly refreshed, while a more profession HR function should be tasked with real succession planning and identifying and supporting budding leaders for the future. Like the best organisations already do.

Brave new world

The big question remains. Is community pharmacy brave enough to go for this? The main trade associations, who would find themselves on the main governance and strategic group under Professor Wright’s proposals, issued cautious welcomes on the report’s publication on 19 June (see box below). Independents will, not unreasonably, be concerned about marginalisation, and the review recognises the challenges involved in creating the single voice for the sector that it sees as vital to obtaining better outcomes from the contract, through clarity of purpose. We hardly need reminding that the last attempt to do that ended in failure in 2017, after less than seven years. 

Given that the review team’s expansive approach to listening to the sector to identify the problems that need fixing, the recommendations – all 33 of them – need to be taken seriously. The prizes on offer, according to Professor Wright, include better communication, a clear line through to those taking decisions on your behalf, and greater transparency over who is spending your money on what, and why. 

But the world is moving on quickly. Over the last two months particularly, it has become clear that coronavirus has accelerated decision making because decisions had to be made. That genie is not going to be put back in the bottle. No-one told the review team everything was fine and dandy. Pharmacy cannot afford to waste time cogitating for too long – Professor Wright suggests two years maximum – about who sits where. The expertise and experience as to what will work for the next stage of community pharmacy's evolution lies across the system, and it needs to be harnessed to  prepare rapidly for something different, and better.  

Immediate reactions

Mark Lyonette, chief executive, National Pharmacy Association 

“If adopted, these recommendations will amount to a radical overhaul of how community pharmacy is represented and supported in England.

“The NPA won’t rush to judgement on the proposals; instead, it’s our job now to help independent pharmacies and local representatives of independent community pharmacy to examine the implications, and to anticipate any unintended consequences. It will take time to build awareness amongst very busy contractors and plug their informed opinion into the discussions ahead.

“A key question for us is whether the changes proposed will deliver a better, more sustainable NHS contract for our members than they have now.

“Whatever structure emerges needs to allow the distinctive voice of independents to be heard, and must work for everyone, big and small.”

Malcolm Harrison, chief executive, Company Chemists’ Association 

“We are pleased this report reflects many of the recommendations the CCA submitted to David’s review team. We fully support the overall focus of the report’s recommendations on improved governance and value for all contractors. 

“The scale of the change recommended is considerable and will take time to translate into action. We need to maximise the unique opportunity this report gives the sector and work together to deliver the changes that will benefit all contractors. Success will mean that all parts of our sector are fairly represented at a local and national level, and the right governance is in place to support the delivery of better value for money for contractors.” 

The full text of the review can be found here




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