Q: My PCT has five different cluster groups with five commissioning leads all with their own plans and perceived needs. Is there a danger the public will get mixed messages because the needs of the different cluster groups will differ and a pharmacy service commissioned by one group may be available in one area but not in another cluster group’s patch?
Panel Member 1:
“Done properly, different clusters can appropriately provide different services, especially if there is no geographical overlap. These clusters are presumably commissioning for their own populations, but they could commission across the whole PCT, or they could view their service as a pilot which can be rolled out across the city once the bugs have been ironed out. If there is inappropriate variation, have a word with patient representative groups, and wind them up to ask questions about equity of services and how robust the needs assessment process and consultation was. The key to this question lies in the hands of the patients - a queue of unhappy patients will soon change people’s plans.”
Panel Member 2:
“At the end of the day, the needs of most areas are very similar with some differentiation resulting from demographics and deprivation. We must also remember that PCTs remain the ultimate commissioner and are held accountable for delivery of services to meet the needs of their patients, who the provider is may vary and will be dependent on capability, capacity, effectiveness, cost-effectiveness, access, location etc.”
Panel Member 3:
“One of the contradictions inherent in PBC is that for it to work it must lead to differential provision and access. PCTs are tasked with ‘holding the ring’ and are very much struggling with this. Differential provision is appropriate in some instances for example where one cluster is centered around a hospital and another is at some distance leading to much greater patient travel. Inevitably there will be places where the difference is stark. In the event of any really significant service differences, which could lead to differences in morbidity or mortality, then the PCT must address this by commissioning the service across the whole patch.”
Panel Member 4:
“This, in some ways, is no different to the provision of different services in different PCTs. Ultimately decisions should be made on patient need. However, as a first step, most PBC groups will pick pet subject areas they feel confident about. It is important for pharmacy to engage with whomever but be prepared to explain to patients why there are differences between different groups. Pharmacy being disengaged will not change the services that PBC is looking to deliver but I agree that patients are the key to changing variation in service and pharmacy should not aim to take responsibility. Ultimately we are the providers not the commissioners.”
Panel Member 5:
“The priorities set out in the PCT’s local delivery plan should be addressed by the practice based commissioners, regardless of how many clusters there are. Clusters ensure local sensitivity rather than bringing inequalities, especially if the funding is set fairly.”
Q: I am an LPC member and a member of its PBC subgroup. We are having great difficulty in getting representation on anything to do with PBC, especially representation on the PBC board. The chair of the PBC board (a local GP) is anti-pharmacy and we are struggling to get to grips with PBC issues. What should I do?
Panel Member 1:
“I suggest using the community pharmacy strategic commissioning tests (see NPA Summer Flyer) as leverage as these have come down from the DH. Building relationships with commissioners in PCTs and PBC groups is not a quick win; perhaps a business case built on reduced waste or unplanned admissions or attendances would be a way in. Getting existing pharmacy services embedded in redesigned care pathways is another – it does not cost them anything to optimise existing services funded through the global sum, just a mindset change.”
Panel Member 2:
“This is tough. Ultimately there is a need to build relationships and the route may be to find other more sympathetic GPs who can influence the decision making process. Also talk to the PCT about how they are performance managing activity and the open transparent system for all providers to bid.”
Panel Member 3:
“This is the issue at the heart of PBC and there are no easy solutions. PCTs are finding it difficult to engage GPs in PBC and so turn a blind eye to shortcomings on stakeholder engagement. I expect your PBC collaborative has established itself as a legal entity and will have a degree of freedom to invite whom it chooses. Your tactics will need to be tailored to the local situation but some generic ideas include: attach yourself to work streams/project groups as a professional advisor looking at specific issues e.g. unscheduled care (admissions from nursing homes); find and cultivate relationships with other GPs who are influential; leverage access via the PCT on their workgroups – many PCTs will keep control of big service redesign projects. None of this will get you a seat at the table in the current climate but it will start to build relationships and demonstrate the value of collaborative approaches.”
Panel Member 4
“There is no absolute rule that states that there has to be pharmacy representation on the board. There are multiple entry points to a PCT, such as meeting with the exec team, discussions with the non exec chair. Produce presentations detailing the improved patient pathways that address local priorities.”
Q: I own an independent pharmacy and our patients have shown interest in a weight management programmes if it were run in house. Which organisations should I contact ahead of setting up such services and is there any grant money available to start the project, other than from PBC?
Panel Member 1:
“The DH does have some direct funding and all PCTs/local authorities have reasonably large budgets often held within public health pooled budgets to try and tackle obesity, particularly in children. The Coventry model is interesting and the early data is promising. There is always the option for a single independent or group of pharmacies in a locality to bid for such services, particularly if they are in a deprived area and could be linked to GMS QoF requirements on BMI which GPs are not too keen on. It could also be linked to a more holistic healthy lifestyle risk assessment which brings in diet, exercise (step-o-meter initiative?) and smoking cessation plus risk screening for vascular disease (hypertension, CHD and diabetes).”
Panel Member 2:
“My advice is always try and find someone providing a service as they will have done a lot of groundwork and we should all learn to share learning.”
Panel Member 3:
”As a commissioner, I am concerned that the evidence base for clinically effective interventions in this area is not strong and the costs are potentially quite high. To move forward you need to test with your PCT commissioners whether this is something they would be interested in. If not then don’t waste your time with the public sector. I also suggest that you look at the Euroaction study which is likely to set the future course for weight management in the context of coronary disease”
Panel Member 4:
“Look at what resources are available locally. Define the priority more specifically and refer it to the LDP. Get patients involved formally. Look at the whole resource pool rather that just the financial resources. Capital grants are easier to access than revenue. Look at external sources of funding.”
Q: This is probably the most significant address of PBC I have seen from a pharmacy perspective in a long time. The idea of a week devoted to PBC is great, and I hope it liberates movement and change. Well done. It just so happens I am meeting with one of my local GPs to discuss some reciprocal work in return for clinical tutor independent prescriber guidance provided over the first half of the year. It will be at this meeting I hope to unveil their service plans etc. I was wondering if I could ask what you suggest I include in my preparation for this meeting. My goal is to use this reciprocal work to drive deeper engagement and fuel the relationship.
Panel Member 1:
“Before embarking, you need to have thought through a business case. It doesn’t need to be presented at the first meeting, but you need to have it clear in your head before you open discussions.
• What service do you want to provide and what evidence is there that it will be successful?
• What is the benefit of this to GPs and patients (workload, income, convenience)?
• What outcomes will be improved – these need to be measurable – reduced hospital admissions, reduced days off sick?
• What will this cost them?
• What are the risks and what will you do to manage them?”
Panel Member 2:
“I would add that needs assessment must pre-empt all activity. Too much commissioning has been, and still often is, based on what providers want to deliver not what is needed. Pharmacy is often guilty of this basic omission in the commissioning cycle. So my recommendation is to do some research before the meeting, look for service gaps or high cost areas in referral and unplanned admissions. Most PCTs/PBC groups are looking for support in reducing prescribing costs, waste and unplanned attendance/admissions. Anything that can deliver some of this in a cost-effective manner will normally hit the spot – try targeted MURs, repeat dispensing and interventions on effective and cost-effective prescribing (preferably without shooting Cat M funding in the foot). Same goes for QoF shortfall – check out where offering improved access through pharmacy can make a difference with risk assessment, screening, monitoring, inhaler check etc.”
Panel Member 3:
“I think you are taking the right approach. Competing with GPs or attempting to substitute for them is not proving to be very productive. The name of the game is minimising costs through better management or timely intervention in order to keep people out of hospital. Pharmacists have a lot to offer in this area.”
Panel Member 4:
“I think all the other suggestions are right. This is about creating partnerships which then deliver through a health care team to meet the needs of a local population. The most important aspect is being proactive in the process and not just waiting for it to happen to you. In developing the partnership, ask the GPs which areas they have concerns about and where they believe the patient pathway could be improved and then make suggestions on where you fit into the modified pathway.”
Panel Member 5:
“What added benefits to current and proposed care pathways can pharmacy provide? Set out your stall and tell the PBC group what services you could provide or have the potential to provide. How can you help them achieve the priorities, as set out in the LDP?”
Q: One of our PCTs has indicated that they are planning to move all their funding for pharmacy local enhanced services (LES) into PBC clusters. The PCT plans to hold no budgets itself. Apparently the clusters would be instructed from the outset that there are some ‘must do’s‘, which would enable the commissioners (who, incidentally, attend LPC open-session meetings), to ensure that those LES currently commissioned (smoking cessation, EHC and several others) will continue. The PCT believes there are a number of advantages:
• it signals to all providers a clear way forward for commissioning (i.e. PBC clusters identify service needs and commissioners commission)
• it deals with contestability issues, because expressions of interest can be made by any suitably qualified providers
• it halts any activity of PBC clusters where GPs are considering commissioning from themselves (it is definitely going on, apparently!)
• it will enable a transparent, level playing field
It also occurs to me that this simple move will enable the PCT to ‘tick all the boxes’ with regard to the ‘downward pressure’ on it to engage with pharmacy and move forward with PBC at the same time.
Has anyone else any experience of this, or any views?
Panel Member 1:
“I suppose that there are some potential advantages and risks for pharmacy with this move, but I have no experience of it locally. I assume that global sum funding for GMS and pharmacy will remain at PCT level? It is vital for all contracted providers that the PCT ensures that a level playing field, a transparent governance and commissioning framework and equity, plurality and contestability, are all in place with appropriate challenge pathways should anyone of these be seen to fail any party. Within PBC, the ultimate commissioner remains the PCT, and accountability very much sits with the senior managers and the PCT Board.”
Panel Member 2:
“The logic of this move is in accord with guidance on PBC and with the general thrust of commissioning policy. The services commissioned in this way are part of care pathways and all commissioning should be made along these pathways – that is how we improve care and how we get a clear picture of how resources are used. To understand the impact/risks it is helpful to make the distinction between purchasing and commissioning. The former is a stage in the commissioning process. PCTs will make decisions about purchasing and changes should only be made by PCTs.”
Panel Member 3:
“The ultimate aim is to get clusters to be the most effective commissioners they can be and if, by giving them the budget this helps, then it is the right way forward. Communication is the the key if it is to succeed. If the LPC is attending, and meetings are public, then transparency has been achieved; all stakeholders must feel they can influence the eventual decisions.”
Panel Member 4:
“I think this delegation is a good thing as it allows engagement at a local level, rather than trying to negotiate with a megalithic bureaucracy. There is potential for different clusters to want different services, but run with the early adopters, demonstrate quality and cost effectiveness and the others will want a piece of the action.”
Q: I am the chair of an LPC. We are actively seeking new funding streams and have sought the views of pharmacist and staff colleagues to discuss the provision of future services locally mainly via PBC. My LPC colleagues have expressed a concern that the chair of the newly formed PEC is also on the board of a company who themselves are bidding locally for contracts. The chair will of course be able to influence the bids as he sits on the commissioning committee. Are there protocols and controls in place that will demonstrate with openness and transparency the independence of the commissioning groups?
Panel Member 1:
“Whilst there will always be some grey areas with potential conflicts of interest between commissioning and provision and so called Chinese walls, I believe that this goes beyond the boundary of acceptability. In our area, this formal dual role is not permitted and one or two have resigned from one of their posts where conflicts of this nature have arisen. The DH guidelines should be enforced or situations formally challenged through the appropriate route where they arise.”
Panel Member 2:
“This is a problem that is raised in a number of forms across the whole country. Make no mistake – the problem is a real one and PBC collaboratives can marshal many arguments as to why newly commissioned services should be given to primary care providers without recourse to a proper competition. They have a very powerful hand to play and PCTs may be inclined to acquiesce with the idea that they can address this and value for money issues when the contracts come up for renewal.
There are plenty of grounds to challenge this situation although you need to ask yourself whether this approach will yield the result you seek. On the other hand, I think it is a mistake for the pharmacy profession and for LPCs to do anything that frames the debate as one between different professions. PCTs should be interested in good quality providers for clinical services and not in the notion of a fair share out between different interest groups. Pharmacists need to start seeing the NHS market in terms of provider opportunities, not professional opportunities.”
Panel Member 3:
“There are safeguards suggested in the PBC guidance on avoiding conflict of interest issues and PCT boards can call on PEC members from nearby PCTs to help in the process. The provision of care must only be a secondary call, after effective commissioning with the commissioning process driving the whole agenda – the local delivery plan (LDP) and its interpretation is key. Meetings of the new PEC held in public with minutes available to all can ensure transparency. The SHA can be called on if there are any issues of impropriety.”
Panel Member 4:
“Ultimately the commissioning is done by the PCT, not the PBC and the PCT must have governance arrangements in place that ensure transparency and probity.”
