Baby. Bath water. Don't
Professor David Wright’s review of community pharmacy representation in England pulled no punches. A review asked for by the Pharmaceutical Negotiating Committee (PSNC) essentially recommended the dissolution of PSNC in its current form; it was also rather damning of local pharmaceutical committees (LPCs). Fortunately, it set out a constructive path to improve the situation.
The drawing back of the curtain on the machinations of the PSNC negotiating team will shock most of us. The contrast with the approach of our GP peers in the BMA is almost painful. It is a structural failure and is not the fault of the individuals involved.
The review sets out what needs to be done to address core failings and remedy local deficiencies. It recommends a cash grab from LPCs that hold more than six months’ reserves to fund investment in the negotiating team and the rest. If your LPC has more than six months’ cash for no good reason, I’ll be blunt: you are being underserved. The cash grab should be approved.
Most LPC spending covers paying people to attend meetings, employing someone to organise them, and the PSNC levy. Developing services, building relationships and supporting contractors is a marginal cost for many. This needs to change, and in many LPCs it has. Increasing the geographical size of LPCs will average up the resources and increase the pool of experienced voices that can be represented on each.
LPCs exist on a spectrum, from poor to superb. The review correctly highlights the need to reduce variation and improve value for contractors. The national pooling of support functions has merit, but there are many excellent staff in LPCs now that can provide such a function without their job being relocated. Regional pooling should be a first step.
The proposal for central control of budgets represents a serious risk to local innovation and improvement.
PSNC and LPCs are often populated by strong voices, in positions for decades. A three term limit, as recommended, will increase diversity and representation as well as accountability, but institutional memory could be lost if enacted without thought. Perhaps a percentage of positions should be grandfathered for an additional term to minimise the risk?
The review highlights the benefits that progressive LPCs bring to the local pharmacy economy in developing services, raising standards and improving representation. Where they occur, it’s because contractors have chosen to invest locally. The proposal for central control of budgets represents a serious risk to local innovation and improvement. LPCs should be free to invest in local projects, without fear or favour. Greater transparency and oversight will prevent abuse.
I’m really pleased to see the urge to re-establish a unified and coherent policy and communications team. I’m equally impressed by the idea that each LPC should have the same. An oversight and governance board can only be a good thing. Sunlight is the best disinfectant.
If you own a pharmacy, there are three ways of growing your bottom line. You can buy or dominate a competitor, you can increase the size of your market if people buy more services, or you can increase your margin by reducing costs or charging more.
The eight Company Chemists’ Association members, who own almost half of all contracts, can no longer grow significantly by acquisition. As market growth through new services is sporadic, the only option to increase shareholder return is to reduce costs and increase margin, hence the drive towards automation and vertical integration, and questions about whether that puts them at odds with the rest of the sector.
It is in that context that Professor Wright’s review has to be viewed. When I first read it, I was thrilled at the extent to which he criticised the structures community pharmacy in England relies on. But I am concerned that if the move from the current structure, where independents have parity of votes with multiples, to a Community Pharmacy England Council (CPEC) comprised of LPC chairs progresses unchecked, I can see multiples using block voting at LPCs to dominate the future CPEC.
Professor Wright’s recommendations are researched and reasoned. Who can argue against the need for a single national voice at a political level (apart from the NPA, who actively dissolved Pharmacy Voice)? Who can argue against the levelling up of LPCs by giving them quality back office resources?
The vast majority of the review needs to be embraced by the sector and enacted at pace, and specifically in time for the next major contract negotiation. We must not allow the genuine concern that voices could be marginalised to undermine or delay that process.
Neither PSNC nor LPCs are fit for purpose. That’s harsh but true, and any step forward we take now needs to reflect that reality, but please don’t throw the baby out with the bath water.