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Stronger why makes for easier how


Stronger why makes for easier how

By Rob Darracott

At the start of the lockdown, NHS England and Improvement (NHSE&I) advised GP practices to consider putting all suitable patients on electronic repeat dispensing (eRD) as soon as possible. A service introduced in 2009 as a non-compulsory method of dispensing prescriptions electronically: the one that 10 years later became a contractual obligation for all patients where clinically appropriate. The one that could save 2.7 million hours of GP and practice time if 80 per cent of all repeat prescriptions were issued through it. But one that has proved stubbornly difficult to implement. 

Mike Maguire’s interest in changing those numbers predates the pandemic by more than six months. “The initial challenge was to persuade the local NHS England team that eRD was something that should be progressed,” Mike says. “The project initiation document (PID) went backwards and forwards, but we managed to persuade them it was the right thing to do. They gave us a small amount of funding to set something up with a practice in Darlington.” 

Prescribing at the practice was running at just under 2 per cent eRD each month. “They were dabbling in it,” he says. “We believed eRD is not that difficult – there are processes you have to get right, but it’s achievable. But we kept hearing people say eRD was a slow burner. One medicines optimisation pharmacist said it would take the average practice five years to get the hang of it. I’m like ‘are you kidding me?’. We were determined to prove that wrong.

“We decided to approach the practice in two ways. The first was why you would want to do it. The American leadership guru Jim Rohn says ‘when the why becomes stronger, the how becomes easier’, so the first part was convincing the surgery of the benefits, for them, the local pharmacies and the patients. Once they understood the why, we could focus on the how.”

It worked perfectly. It’s little things like that which help to build the right environment

Mike and his colleague Andre Yeung, who is now making his own waves as a newly elected member of the RPS Assembly, approached other practices in the area for help with the technical aspects, and recruited their best team members to work with the target practice, half a day a week. He remembers one person particularly. “She was ’just a receptionist’, she said, but she knew SystmOne and eRD inside out. She was exactly what we wanted.

“The other part of the ‘how’ is about the wider stakeholders and the relationships – with community pharmacy, for example. They weren’t great in Darlington, so we had a stakeholder event. We invited the practice we were working with, the teaching practice, the pharmacies in the area. We mixed everyone up. I threw out what we wanted to achieve, and said ‘let’s talk about it on the tables’.  It was a safe space to talk. 

“I suggested they look at the barriers and then think of solutions. As an example, one practice said that every time they phoned Boots, they got the make-up counter, then the perfume counter, then when they got through to the dispensary, nobody picked up for five minutes. Pharmacies were saying ‘when you phone the surgery, it’s press one for this, two for this, you are on hold for ages’. 

“Communications were a big barrier. When you’ve got eRD for six months or a year, a concern for practices is medication changes. We needed a slick process to manage this. This is where relationships come in. You build them and they are there when you need them.” 

The solution: a mobile phone in the Boots dispensary – a direct dial number for one practice, and a direct dial number for the practice for Boots. “It worked perfectly. It’s little things like that which help to build the right environment,” he says. “They were at 2 per cent eRD. We had a stakeholder event on 12 September, and by December they’re were above 30 per cent eRD. It proved our theory; all this ‘slow burner, it’ll take five years’ is a load of rubbish. 

“Sometimes it’s an attitude where if you don’t promise much, or you say something will be very hard, then you are not judged when it does take a long time. It’s quite scary saying you will do something in three months. That’s unnerving for some people. Me and Andre egg each other on, to be honest.”

The snowball effect

From their initial success with the first practice in Darlington, things snowballed quickly. “That was NHS England,” says Mike. “We wanted to do area by area. By November/December, as we were working well with one practice, we wanted to expand to the rest of Darlington. It’s a big primary care network (PCN) – 108,000 population – and they said ‘when you do Darlington, let’s have a look at North Cumbria’. That’s more challenging [big geography, dispensing doctors].”

They agreed, then Covid hit. “They asked us to ramp it up to the rest of the North East. We said, ‘yeah, of course’. Then they said they’d put it up to Alex Morton, the director of primary care and public health commissioning, North East & Yorkshire, NHSE&I, and she asked us to do Yorkshire as well. We went from one practice to five practices to 1,035 practices.” 

Individuals have different needs and they all have different rates of change. For me, the fundamental is the ‘why’? 

The escalation of demand meant a change of approach. He says Covid helped with eRD. “You wanted to reduce patient contact. What better way than to put patients on eRD, with a year’s worth of prescriptions?” Then NHS England backed the move nationally, and wrote to GPs. “They could see the value.”

As for community pharmacy, as well as smoothing prescription flows, Mike says: “Durham & Darlington LPC chair Dawn Cruickshank did some work with her local practice a couple of years ago. She found eRD massively reduced the number of deliveries because patients got medicines once a month rather than in dribs and drabs. And obviously it was better for patients, when we are trying to keep vulnerable people at home. So Covid was the best time it could ever be for promoting eRD.”

The half a day a week handholding with ‘subject matter experts’ was out, both because of Covid and the challenge of 1,035 practices. The stakeholder events with local pharmacies were out too. The solution was to recruit LPCs to cover the pharmacy side and sign practices up to a series of webinars. Instead of handholding, an NHS England email address routed any eRD query to one of its experts, including Mike and Andre, with a 24-hour turnaround, a promise they have kept since the system went live at the beginning of April.

“The 195 practices that came on the original series of webinars we’ve divided into three – around 100 high eRD (doing well), 60-odd low but growing (moving forward), the rest low but not growing. The high ones we have asked to share their good work within the PCN. We see that as an opportunity to spread success. The others we will be phoning to see what barriers they have. Talk to them one to one.” 

With 1,035 practices on this list, there’s still a lot to do. “The second phase is re-engaging,” he says. “We were commissioned to do three months to start with, and we’ve been given another three months for phase two. It’s not confirmed yet, but we want to do all we can between October and next March with the ones who still haven’t taken it forward. The aim by the end of March is to get all practices using eRD, and quite a lot of them being high users.” 

I ask what Mike’s experience tells him about change. He says: “Individuals have different needs and they all have different rates of change. Some are more resistant than others. For me, the fundamental is the ‘why’? 

“There are still people who don’t get eRD, but to be fair to them, I think it was badly sold in in the first place,” he says. “If you’re told it might take five years and to focus on thyroxine, GP’s will be thinking ‘people on thyroxine aren’t my worst problem’. And GPs anyway aren’t the right people. The main people are the prescription admin team. They’re the ones who will do the work and get most benefit from it, then the system within the practice works more efficiently, and then the GPs will benefit.” 

Trust and relationships matter too. “When I was an LPC chair, I remember PSNC telling us ‘you need to build relationships with public health’. But you can’t just pick up a phone and say: ‘I need to build a relationship with you.’ It’s the same with primary care networks. Before I was on an LPC, if someone had said to me you need to build a relationship with your PCN, I’d have been really daunted. 

“What I would suggest is that you talk to GPs about something that interests them. Attract their curiosity. It’s the way we used to do healthy living pharmacy. If you ask someone how much alcohol they drink, they aren’t interested. If you attract their interest with a campaign so they ask you what’s going on, you get the conversation. So, with PCNs, or if you’ve got eRD working in some practices and not others, do your homework. Ask how you can support the practice that isn’t doing so well.”

Second generation in Middlesbrough

Mike is a second generation community pharmacist. His father opened Marton Pharmacy in Middlesbrough in 1961. He joined the practice in 1989 and gradually took over. “We were a typical family business, reactive rather than proactive, didn’t really have a strategy, training the team when it became mandatory,” he says. After relocating the business in 2005, he says they started to struggle financially. He had the biggest unit in a new building, with a therapy centre with rooms for rent and a second pharmacist. 

“It seemed like we were doing brilliantly, but the costs were overtaking the income and I didn’t have the skills to manage that.” A conversation with his financial adviser changed things dramatically. “He told me about a company called Lifestyle Architecture. I said I didn’t have the time. He said ‘I’ve known you a long time and it’s like this: you’ve got little or no leadership skills, your dispensary team have no direction, your business is a big ship drifting aimlessly towards disaster.’ I thought, ‘cheers, mate’. The more I thought about it, the more I realised he was right. I got in touch with them and became a student.”

A year later, Mike won a Community Pharmacist of the Year Award. “I was stood on the stage thinking ‘flipping heck, this Lifestyle Architecture stuff really works’,” he says. “I’d turned my business around, won this award, things were going well. It carried on. In 2014, I became a Lifestyle Architecture practitioner, with a licence to share the concepts and principles. 

“I’ve branched out, worked with schools, the hospitality sector. It’s helping people to find their own way, using a series of concepts and principles to guide people. I’m a pebble chucker. I chuck pebbles into people’s minds and see what ripples come out. And I have a wardrobe of solutions that I can pick from to help people in their situation. I use it a lot day to day in behaviour change. 

As the chair of Tees LPC, and an award winning community pharmacist with leadership experience, Mike Maguire might have seemed a natural choice for local professional network chair, when the roles were created by NHS England in 2013/14. But that’s not why he was initially interested in the job. “I knew some of the people who were going for it, and I really didn’t want them getting the role because I thought it would go down the wrong route. So I almost applied to do it to stop someone really bad getting it. But I thought I could take it in the right direction,” he says.

“The main role is advising commissioners – local authorities, CCGs – how to do things differently for the benefit of patients and the system as a whole. You could also call us a critical friend of NHS England. I do have freedom to stretch the boundaries, and we do that a lot.”

Mike started as LPN chair for Durham, Darlington & Tees. Andre Yeung was a member of his steering group, before taking on the LPN chair role for Newcastle and Northumberland. The pair have become friends, colleagues and business partners - a pharmacy Ant and Dec. They now manage the LPN role in Cumbria too. “We used to have three half days a month. We now do the whole geography between us on two and a half days per month. Projects are different, they have separate funding.”

Then there is the work that led to the national Community Pharmacist Consultation Service (CPCS). Mike says he and Andre were there from the beginning. “It started on 12 August 2014; that shows how long innovation takes in the NHS.” He remembers the date because it was his daughter Sophie’s birthday. BBC Radio Tees wanted a comment on new research that showed community pharmacy bucked the inverse care law – that the more deprived a community, the poorer access there was to services. The radio station wanted Mike to go live at seven o’clock in the morning. 

All of a sudden, we are scrambling around trying to see what’s gone wrong.

That broadcast led to a meeting with Peter Hayward, the clinical lead for NHS 111 in the region, who was looking for a better alternative to A&E, out of hours GPs and walk in centres for calls about common conditions like conjunctivitis, diarrhoea, coughs and colds. “That’s how it started,” Mike says. “We then had a mission to get it commissioned.”

He hasn’t been involved with the roll-out, either nationally or regionally, but he’s seen the latest stats. “I saw Keith Ridge’s tweet about 332,000 referrals since October, which is some going really. Every single one of those patients would have gone to a walk in centre, an out of hours GP or, worse, to A&E. Even if two out of 10 get referred on, that’s a massive win. I’m really proud of it.”

The right thing to do

“You do things because it’s the right thing to do, and sometimes you see the benefit straight away, and sometimes, like with CPCS, it’s a bit later.” 

Mike says he recently learned that his early morning appearance on Radio Tees made an impression, when a fourth year student at Nottingham University came up to him after a presentation there to say she’d heard him talking on the radio and decided she wanted to do pharmacy. “You don’t know the impact you have when you do stuff,” he says. “It can come back to you years later.”

He sold Marton Pharmacy in July 2018 to concentrate full-time on his LPN role, projects that interest him like persuading GPs of the benefits of eRD, and his work helping others as a Lifestyle Architecture practitioner (he’s open to offers). I ask what he misses about pharmacy? 

“The people that thank you,” he says. “From a professional point of view, being told you’ve changed someone’s life is the thing. I was really proud of Marton Pharmacy and what we created, how we interacted with the community and had such a massive presence. Karen [Mike’s wife] and I can’t go into Tesco without someone coming up to me to thank me for what I did. That’s really nice.” 

Now he follows what’s going on in the sector, he says, because he needs to for his LPN role, but also because he likes to. And one of Mike’s daughters works in his old pharmacy, so he hears what’s happening direct from her. “I stay fairly close to it,” he says.  

I’m speaking to Mike on the day David Wright published his review of representative structures. He’s already read it. “Community pharmacy used to be a comfortable living with a good margin,” he says. “Gradually, that’s been eroded. I understand that taxpayers should be getting value for money, but I don’t think community pharmacy as a sector has reacted to that direction of travel quickly enough. All of a sudden, we are scrambling around trying to see what’s gone wrong.”

He cites the absence of the right kind of relationships as symptomatic of what needs to change. “If you want to build relationships with MPs, for example, you don’t wait till everything has gone wrong – you build them over time. Some years ago, PSNC invited me to a session with MPs in Westminster. It was a good session, but as MPs arrived, people were checking their phones trying to match MPs with their pictures because they didn’t know what they looked like. My MP walked in and its ‘Hello Mike, have you seen who the Boro’ have signed?’ I build relationships as part of what I do.”

How do you relax?

Spending time with my wife Karen and my children. In spite of having six of them, I still enjoy seeing them. I’ve loved spending time with my family during the lockdown. It’s something you always mean to do, playing daft games in the evening, or doing quizzes. The other love of my life is the Boro’ – Middlesbrough Football Club. More downs than ups recently, but the European adventure when we got to the final of the UEFA Cup was great, winning the Carling Cup, the crazy Juninho years, two cup finals and a relegation in one season. A couple of years ago when we got promoted, me and Karen got invited into the players’ private party [then manager Jonathan Woodgate’s parents were customers]. 

What are your major career highlights?

Pharmacist of the Year, and getting an award for innovation a year or two ago with Andre and PharmOutcomes for CPCS. I’m really proud of Marton Pharmacy and our presence in the community. The British Heart Foundation did a video on how I changed a patient’s life. I evolved the LPC to a stage where it has gone on the be one of the best in the country, and to be fair to those who’ve taken it on, it’s gone from strength to strength. HLP in Tees was something I started. I managed to get four local public health teams to pay £25,000 each in to fund it. Sandie Keall, who was the project manager, is now the LPC chief officer.

What personal ambitions do you have?

Continuing to make a difference to people’s lives. With a pharmacy, it was one-to-one; now I’ve got the opportunity to do it on a bigger scale. That’s what I like about the Lifestyle Architecture stuff – you can share what you have learnt. It’s nice when you can give people a helping hand up. 

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