C+D Senate: The shift to service provider
Topic: Making the shift from volume dispensers to service providers – how can it be achieved?
Senators answer your questions
Question 1: What should community pharmacy look like in the future?
What you said: Over half of pharmacists would be pleased about community pharmacy becoming a more clinically focused sector, with 60 per cent of respondents to a pre-Senate survey saying it would mean they could focus on their patients.
Not all were convinced, however, with 31 per cent saying they were concerned by the prospect. Of those, 58 per cent said they did not feel pharmacists had the required skills, and 42 per cent felt they would be up against too much competition.
What the Senators said: Several C+D Senators were quick to agree that the current community pharmacy model was ‘broken'.
As NHS Employers' lead negotiator for pharmacy Felicity Cox concluded: "I think there is an awful lot more pharmacy could do to support the NHS."
However, there were a lot of people that needed to be convinced about this, she warned.
Lloydspharmacy head of professional and external relations Ronan Brett gave his clinical vision for the sector. "Pharmacy needs to be empowered to be the full clinical extension of what it can be – I want to see it becoming the clinical focus of the community," he said.
To achieve this, red tape would need to be cut, alongside any remuneration changes, he suggested. "I think there is a general appreciation that community pharmacy has to change driven by a reduction in the bureaucracy."
Mr Brett also called for more debate about how the sector could make the transition to a new way of working. "What I would like to see in the future is a bit more activity. [We want to say] we are here today, that is where we want to get to, what does the transition period look like? That is the big question," he said.
Chris Howland Harris, a pharmacy contractor from Bristol, agreed but questioned Mr Brett's assertion that pharmacy needed to "take a risk" to get to where it needed to be. "Ronan has really hit it on the head with the issue of transition," he said. "I can see there is a lot of investment required, and I am prepared to spend money and to invest and develop my pharmacy, but I can only do that if I have the security to know that I will still have a business and an income in the 10 years it will take to pay off that investment. And that is a real stumbling block for a lot of contractors."
Senate verdict: It was agreed that a new model for community pharmacy was needed, but how much financial risk should be involved in that was up for debate.
Senators warned that there needed to be a clear vision for the future and that care should be taken in any transition period.
"Unless there is a change of focus, there will always be activity for the sake of activity as that is how we are funded – and it is the wrong way around," said Mr Howland Harris.
Question 2: How should that new vision be funded?
What you said: Despite the strong support for adopting a more clinical role, many pharmacists have concerns about remuneration.
Half of C+D readers responding to the Senate survey said they would be worried about delivering a contract that rewarded service delivery, while 39 per cent would be pleased. Meanwhile, 11 per cent would be angry about adopting a service-based contract after signing up for a volume-based model.
One pharmacist commented: "Someone still has to dispense medicines, so we have to ensure we don't give up dispensing, which is our core strength, for services. Services must be seen as added value to our core function, otherwise pharmacy will not be sustainable as we know it."
What the Senators said: Most Senators agreed on the need for a new financial contract for community pharmacy. Ms Cox called the current system "wrong", while Mr Brett said: "It's perverse that at the moment we should have a system where we're not rewarded for not dispensing medicines."
"The fact [is] that our current contract does seem to be broken," he concluded.
John Murphy, director of the PDA Union stressed that new models should be considered.
"I think we're in danger of thinking the current model is the right one and getting into a vortex of despair," he said.
But some Senators had concerns about the impact a new contract might have on businesses.
"We wanted to establish a funding model that wouldn't have a massive impact on contractors around the country, and every single model we looked at fell down on that point," said Sue Sharpe, PSNC chief executive.
Minimising that risk would require support from the NHS, Ms Sharpe stressed. "It's about trying to get that confidence [from contractors] and the NHS being prepared to provide that support through the transition period," she told the Senate.
"I think the NHS has to understand the realities of change and [that] a raft of additional investment is needed."
Mr Harris echoed the comments. "As contractors, we would like a core, basic, fundamental income so we know we will be supported in providing NHS services," he emphasised.
Meanwhile, NHS Future Forum representative Ash Soni said nationally commissioned services could give pharmacists some income security. And Ms Cox suggested better collaborative working within the healthcare system about such services to ensure they were well-integrated and avoided duplication between providers.
Senate verdict: Change is needed, the Senators agreed. The sector needed to establish "a framework for rewarding and incentivising services at a reasonable level", according to Ms Sharpe.
And Mr Murphy suggested establishing two contracts, one for services and one for supply, which he thought could bring change "without damaging the community
pharmacy network".
Question 3: How do we get the sector ready for this change?
What you said: Respondents to the Senate survey did not feel that they had enough support to be able to enact major changes to their way of working. More than two in five respondents, 42 per cent, said they did not get enough support to deliver the services they would like, and a quarter called for more support to boost their confidence. However, 41 per cent of respondents felt they would be up to the challenge if they were required to meet certain quality standards.
What the Senators said: Getting staff as engaged as possible was key to ensuring that the new medicine service (NMS) was implemented effectively, according to the Senate.
Healthy Living Pharmacy (HLP) project lead Deborah Evans said that early engagement was something she felt "very passionate" about, as it had been done when implementing the HLP scheme. "We as people don't like being told what to do. It's very important that people understand why it is that we are doing it."
Her views were echoed by Mr Murphy, who said that the sector needed to learn lessons from MUR implementation.
"One of the big lessons [that we should take from] MURs was how are we going to get pharmacists involved in the design of the process? Let them know what they need to do in the implementation and that will make them involved. That never happened with MURs, and we need it to happen now."
However, in order to achieve this, pharmacists needed to improve their ability to delegate, Ms Evans said.
Mr Brett also pointed out that implementation would require other forms of support. "The NMS will need new IT services," he said.
Senate verdict: The Senators agreed that to implement the changes the sector needed to be helped and inspired.
And getting the sector ready for change was everybody's responsibility, Pharmacy Voice chief executive Rob Darracott said. "It's not one group's responsibility. I think lots of people have a role to play," he explained.
Question 4: How do we get everyone else ready for this change?
What you said: C+D readers feel optimistic about the future, with 85 per cent believing patients would be receptive to pharmacists delivering more clinical services.
However, the future looks less rosy when it comes to convincing commissioners. Only 13 per cent of respondents to the Senate survey thought their LPC would succeed in getting services commissioned under the new NHS. Just under half, 44 per cent, said they thought getting services commissioned would be tough in the new NHS, while 43 per cent worried the committees would not successfully negotiate many services.
What the Senators said: LPCs would play a vital role in communicating the evolving role of pharmacists, C+D Senators agreed.
"LPCs need to make sure they flag up the things pharmacy does successfully on a national level, because we've got to influence the national commissioning board," said Ms Cox. "I think LPCs could be very powerful in the new NHS."
Ash Soni agreed that LPCs should build relationships sooner rather than later.
"You have to think about where the new world is going and how to build it into your relationships in the future," he told the Senate. "Some LPCs have shown how well you can do this if you do it effectively."
Mr Darracott called on the sector to take a "strategic" approach to working with other healthcare providers. He encouraged pharmacists to talk to GPs about their services "as long as it doesn't sound like you're asking permission".
"We should tell doctors there are changes, but my concern is that we could give doctors the wrong message, which is that they have some kind of veto over these services," Mr Darracott emphasised.
Meanwhile, PDA director John Murphy was optimistic that pharmacy services would be welcomed. "Organisations want to use the skills of pharmacy more and more and I think we should try to capitalise on that," he said. But he warned: "What's happening on the ground is what's going to be important and there will be an awful lot of work to be done locally."
Ms Evans added that there needed to be clear responsibilities within the healthcare system.
"For me it boils down to understanding who does what where, so there are some things that GPs would be happy for pharmacy to get engaged in," she explained. "We are going to be competing with them as service providers so we need to acknowledge that and show that we're cost-effective."
Senate verdict: Pharmacy needs to work hard to demonstrate its efficacy and explain what it could offer in the new NHS, Senators agreed. "GPs are not going to listen to us telling them how good we are. We've got to prove it and if we are good, they will come knocking for us to deliver," said Mr Brett. Deborah Evans agreed: "We need to show that we're a cost-effective provider of NHS services and we need to think very carefully about how we generate that evidence."
The Senators
Ronan Brett: Head of professional and external relations, Lloydspharmacy
Felicity Cox: Chair, NHS Employers pharmacy negotiating team
Rob Darracott: Chief executive, Pharmacy Voice
Deborah Evans: Healthy Living Pharmacy lead, Portsmouth
Chris Howland Harris: Contractor, Ashgrove Pharmacy, Bristol
John Murphy: Director, the PDA Union
Gary Paragpuri: Editor, C+D
Jennifer Richardson: Deputy & features editor, C+D
Sue Sharpe: Chief executive, PSNC
Ash Soni: Contractor, Copes Pharmacy, and pharmacy representative on NHS Future Forum
Zoe Smeaton: News editor, C+D
The C+D Senators answer your questions
Q Mike Hewitson, contractor: If GPs aren't on board with new services such as the new medicine service (NMS), it could be fatal. How do the pharmacy bodies plan to engage with GPs to ensure they are aware of the services, support them and will refer patients to them?
A Rob Darracott: We should contact GPs about the service as long as it doesn't sound like permission. My concern is that we give doctors the wrong message, which is that they have some kind of veto over this. This is a pharmacy service, not a GP service, and actually you could go and do this tomorrow if you chose to do it.
Ash Soni: GPs have six minutes with a patient on average and they have to deliver a number of messages during this time. It may be that this is one of the messages they don't have time to do, so relying on that is more likely to lead to failure.
Q Tariq Iqbal, C+D Community Pharmacist of the Year 2010: Why are pharmacy services being decommissioned when GP services are not being stopped?
A Chris Howland Harris: We are very poor in pharmacy at recording outcomes and MURs are a very good example of this, which is probably why we are moving towards targeted MURs. Unless there's a change of focus, there will always be activity for the sake of activity, as that is how we are funded.
Q @pillmanUK, via Twitter: How do we ease the pain of transition from a volume to a service-based model? Does the Senate see the progression to future models as a carrot or a stick-driven process?
A Ash Soni: We need more effective carrots.
Deborah Evans: From a Healthy Living Pharmacy position, contractors said they got job satisfaction and staff motivation in return.
C+D Senate live: how the debate unfolded
The C+D Senate was for the first time reported live, with readers following and participating via the website and on Twitter. You can see how it unfolded in full at www.chemistanddruggist.co.uk/senate
C+D: A huddle of Senators are already talking shop. This is set to be an interesting debate.
pillmanuk: @ChemistDruggist #cdsenate watching on website and in tweet deck. Postponing my lunch to view the proceedings.
C+D: First question from reader Bhavesh Patel: What services are we definitely going to provide? Are we going to have more services commissioned in future, as we're losing the amount of money we get from prescriptions?
C+D: Rob Darracott answering: Start point is pharmacies being more involved in medicines optimisation.
C+D: One good example of this is Portsmouth, says Gary, turning to Deborah Evans.
CandDJennifer: Getting early buy-in & ownership for change from pharmacists and their teams key to successful change, says HLP lead Deborah Evans #cdsenate.
CandDEmma: Pharmacy needs to take a risk to develop new role – Ronan Brett #cdsenate.
C+D: To John Murphy. What he has heard from round the table is consistent – pharmacists want to change, but are looking for leadership.
CandDEmma: GP services are also being decommissioned, all providers need to prove they are effective, says NHS Felicity Cox #cdsenate.
C+D: Sue Sharpe says the biggest issue is what and how NHS is willing to fund pharmacy in future.
CandDHannah: #cdsenate Pharmacists need assurance that any change will pay, PSNC chief says.
D Sharp: Under QIPP why would the NHS want to pay us for services it already pays doctors to do unless they stop them and pay us less?
C+D: Ash Soni says in response to D Sharp, because this is an imperative and opportunity and that it could be services not already offered. He says to stop looking at medicines management to medicines investment.
GaryParagpuri: Sue Sharpe says every model looking at funding change so far shows there will be casualties #cdsenate.
C+D: Deborah Evans says there is a small window of opportunity to pilot the NMS to look at the potential pitfalls.
C+D: Felicity Cox says the NHS has more pilots than all the airports in the UK *laughs*.
Tips for your CPD entry on NHS reforms
Reflect Do I understand how planned NHS reforms will affect my pharmacy and the services it provides to patients?
Plan Consider how commissioning changes will affect my pharmacy's services.
Act Talk to fellow healthcare professionals and new and future commissioners about the services my pharmacy provides and would like to provide in the future.
Evaluate Is my pharmacy now better placed to win services from new commissioners?
