GP gripes – help us set the record straight

Hi Emma.......

Its a bit lengthy belwo) but in essence its all about commissioning for collaboration not competition.......

Why “Kill Kodak” is the wrong policy for Pharmacy, Patients
and the NHS

During February of 2008, Lord Ara Darzi visited the offices of the Royal Pharmaceutical Society as part of a Society “Darzi Day”.

Frustratingly Lord Darzi managed to omit any mention of community pharmacy during his presentation when describing the need to reduce the complexity of patient pathways as part of the drive towards improving the quality of healthcare across the NHS

Another presenter that day was Gary Belfield, NHS Director of Commissioning. As part of his presentation he described how commissioners should look beyond the confines of the NHS when searching for new and imaginative commissioning solutions. He went on to describe how, in the days of “D&P” before digital cameras changed everything, Fuji were desperately competing with Kodak for market share. Apparently Kodak were the clear brand leaders with Fuji occupying the number two slot. Mr Belfield described how Fuji’s mission statement was “KILL KODAK” and how this competitive approach should be adopted by NHS commissioners.

During questions I took the opportunity to challenge Mr Belfield’s thinking. I asked him if “KILL KODAK” was really the right ethos for primary care commissioning. If what we really want is patient-centred, multidisciplinary care is a “KILL KODAK” approach going to bring that about? Are health professionals from different disciplines really going to work together in a competitive “KILL KODAK” environment? Are GPs really likely to work with community pharmacists, as I believe they should, if we are seen as FUJI and they are KODAK? Let’s face it, all the commissioning “trumps” have been handed to GPs. Does “KILL KODAK” go some way to explain the effective exclusion of pharmacy from so-called Practice Based Commissioning? The reality is that PBC has been more about provision by GPs (who are obviously conflicted and have a vested interest) than true commissioning, a scenario I often describe as Practice BIASED Commissioning

I asked the “collaboration vs. competition” question again during the closing plenary session at last year’s NHS Alliance conference. (The NHS alliance is network of senior NHS managers, doctors and practice managers, nurses, pharmacists and allied health professionals, along with board chairs and members. It has no political affiliation, and works in partnership with the NHS with the aim of supporting the modernisation of the NHS, freed from the traditional tribalism of single interest groups)
In response to my question, David Nicholson, Chief Executive of the NHS, agreed that competition is not the holy grail - it was only helpful if it improved quality of care for the patient.

In a compelling recent Broad Spectrum article,(PJ 03.06.2010) Georgina Craig suggests that, following the recent change of government, GPs will be more in the commissioning driving-seat than ever. She suggests “As with all major changes, what we need to do first is reframe our relationships and conversations — especially with GPs”


Dr Mike Dixon, GP and current Chair of NHS Alliance agreed the need for a new level of engagement and understanding between pharmacists and GPs and supported my argument
Only Professor Paul Corrigan – a former health advisor to the then Labour Government (and an architect of the competitive environment) demurred, and even then only in part. His view was that PCTs had to encourage competition between providers; but at times, seed collaboration as well. A mixture of both approaches was inevitable.

In the paper “Developing Clinical Leadership” (National Association of Primary Care, 2009) the authors argue that developing and supporting strong clinical leadership are crucial success factors for the NHS. However there are systemic issues that must be overcome, including “NHS culture of insularity, short-term thinking, risk-averseness and hierarchy, work load and balance; under-representation of particular groups working in the NHS ….and co-operation within primary care. They argue that “a clear development policy based around risk and financial reward incentives in primary care is required to deliver transformational change in the wider health economy

As I have suggested before, the current community pharmacy contractual framework is not fit-for-purpose. Like many other aspects of the NHS internal market and contracting arrangements, it is full of “perverse incentives” and fails to reward the promise of the Pharmacy White Paper (Pharmacy in England – building on strengths, delivering the future). This, and the level of resources, must change fundamentally and soon. But changing the pharmacy contract alone, will not be enough. If the NHS really wants multi-disciplinary, patient-centred care then it must reflect that in its commissioning strategy and incentivise inter and intra-professional collaboration accordingly.
So far as encouraging collaboration goes, the current pharmacy and GP contracts fall equally short. Both are full of perverse incentives which promote competition NOT collaboration. There is a new team at the Department of Health (soon to have a new system architecture and, it is suggested, renamed the Department of Public Health). It needs to decide what it wants from pharmacy and it is crucial that the profession influences thinking at the highest level. With an increasingly challenging financial climate, it is at last being recognised that the excess capacity needed to drive a traditional ‘competition’ model may not be sustainable or even appropriate. Competition breeds secrecy and the withholding of information rather than sharing, mutual distrust rather than co-operation. This is fundamentally wrong in a healthcare environment.
The Political Dimension:
The lack of political acuity in pharmacy has been one of my long-term themes. By tradition, pharmacists are proudly non-political and we disengage from the political process. This is professional as well as political suicide because it is ultimately the politicians who take the key strategic decisions about the NHS and our roles within it. The political playing field may be very uneven, but often-as-not we are not even on it! This is a tragedy, because when we do engage we can be very effective lobbyists. One need look no further than the very effective and influential All Party Pharmacy Group in parliament to see what we can achieve when we try.
Recently I have been delighted to see all three major national pharmacy organisations getting much more “political”. This can only be a good thing – but too often they seem more intent on competing against one another for the limelight than collaborating, when they should be working together to get the best result for the profession. We still don’t have that much-promised “clear strong voice” – but the potential is there. Our new Professional Body is “just around the corner” now. However it will only be credible and viable if the overwhelming majority of pharmacists join it and engage with it. So must set our doubts aside and help shape it.
We must convince the new government that we are crucial to delivering their health and wellbeing objectives for the NHS. Pharmacy, working in partnership (not competition) with the other health professionals could do so much more to accelerate earlier diagnosis of long-term conditions, improve public health (especially in addressing the health-inequalities agenda) and to optimise medicines management. This could save lives in their thousands and save costs in the £millions. Given the current “cost-constrained, evidence-based” NHS environment we have a compelling argument to put forward.
I recently attended a regional meeting of National Association of Primary Care
{ www.napc.co.uk } This is an organisation that spans all of primary care. My “competition vs. collaboration” arguments were well received…….all the talk was of the need to remove tribalism and to work together in patients’ interests. Encouragingly the term “Clinical Commissioning” is increasingly replacing “Practice Based Commissioning”. More encouragingly still, the next meeting is being held at Lambeth, hosted by the Royal Pharmaceutical Society. We have the positive prospect of a debate on clinical leadership within the NHS, and how Pharmacy can contribute, with an audience comprised of senior NHS personnel and clinical leaders from several other health professions. NAPC offers real hope of partnership working and increasing pharmacy influence. I would encourage as many colleagues as possible to get involved.





In a closely argued paper “Better Practices, Better Health” (London School of Pharmacy, 2009) Prof David Taylor and Dr Jennifer Newbould say “Counter-productive rivalries between community pharmacists and general medical practitioners would leave patient needs unmet and the professions involved vulnerable”. They conclude “ Better joint working between community pharmacists, GPs and other practice based professionals should be supported by a range of interventions, from integrated remuneration systems to personal contacts that promote greater mutual respect”

In Conclusion:

Returning to my premise: competition between pharmacists and GPs, far from improving the quality of patient care is actually having exactly the reverse effect. Competition is preventing GPs and pharmacists from collaborating to deliver the integrated, high-quality primary care that is needed. Competition is obstructing the delivery of people-centred, prevention-focused services. If we are to gain the necessary momentum to position our profession where it needs to be – central to healthcare delivery and public health, then we need to look beyond the confines of the failing pharmacy contract to the wider aspects of how healthcare is to be delivered and paid for in the future. We need to influence the healthcare environment itself, and we can achieve this through a strong and effective professional body. We owe it to our profession, to our patients, and to the public to do so.
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Link back to original article

Hey Emma,

My primary whinge I feel when I work in community is that the GPs and pracitce managers are more focused on their prescribing budgets than actually thinking about the patients.

A large proportion of patients on chronic medication will be elderly. And if the patient were to lose the prescription, the receptionists are anything but friendly or understanding. And so are the practice managers. And it's impossible to get through to the doctor, you're often limited to leaving a message and hoping the said doc would get back to you in a few hours, if at all.

Quite often, if the medication is urgent, the solutions are to make a (technically illegal) emergency supply to cover the 2 days, or if it's something new or infrequent, the patient has to book an emergency appointment.

Essentially, the patient is seen by the surgery as a criminal hoarding (for example) blood pressure medication.

And then the struggle for getting prescriptions in advance for services such as DDS or dispensing for care homes. You get some surgeries with an irrational policy of supplying the prescriptions a week at a time, regardless of how long it takes to assemble or check the medication for the script.

GPs just don't seem to understand that if something needs to change, and they tell us not to dispense a prescription, we won't dispense that prescription.

And errors will happen. It's inevitable. Gps know that, pharmacists know that. Things aren't always dispensed right and sometimes things aren't prescribed right. So when the said good doctor gets a call from a pharmacist/pre reg/summer student/dispenser, there is absolutely no excuse to be rude. We're not calling to make fun at your mistake. We're just trying to keep the patient (who by this time is erupting with 7 shades of hellfire for waiting "ages" at the surgery then having to wait "ages" again in the pharmacy) alive.

Hi
There is a culture of Pharmacists being annoying and lower in status to Drs which starts during medical training and is still endemic across the Healthcare system. Seems to have improved a bit from when I first qualified some years ago but it is still there. Don't know if it will ever be totally eradicated,
Regards

There is a lack of respect shown by receptionists and practise managers towards pharmacists. They act as blockers/gatekeepers to the GP and revel in this position of "power". However, only the GPs can change this within their own surgeries. In my experience, most GPs are very amiable people.

Such GPs have worked closely with pharmacists when working in hospital. However, once a doctor practices as a GP, they become better prescribers and less reliant on pharmacists. Hence, creating a distance/less reliance between the two professionals.

One way to prove your competence to a GP is to show that you have good clinical knowledge and are able to contribute to a GP and their patients in this manner. Sadly, many of our community pharmacist colleagues lose these skills. They should watch and learn what our hospital pharmacist colleagues do in terms of improving their clinical skills in order to contribute to a multi-disciplinary team.

Pharmacists like to call themselves the experts on medicines. It's time for all community pharmacists to prove this. Respect in healthcare will be earned from this.

Thank you for all these comments - we're now finalising the issues to cover in our Senate next week, so will make sure we tackle the GPs on these.

Emma

Thanks all for your comments.

Niall, in response to your concerns, we will be doing everything we can at the C+D Senate to ensure that all pharmacists’ views are heard – we will be sharing the results of our survey of nearly 100 pharmacists on this topic; readers have been invited to submit any thoughts and questions they have and we will put those to the Senators; and anyone can follow the debate live on the day and put further questions or thoughts to the Senators as the discussion unfolds.

We hope that by inviting readers to engage in all of these ways we can ensure everyone’s views are heard on the day.

Please do get in touch if you have any comments or questions you would like us to put to the Senators on Friday. You can post comments below this story or email us on senate@chemistanddruggist.co.uk.

Zoe
First up, many thanks for your reply. I would like to underscore what the heartbeat of this whole relationship manifesto is. For relationships (pharmacists & GPs)to flourish there has to be a vision or an outcome in mind that begins and ends with patient needs. I really appreciate your kind offer to share results and follow the debate but with the kindest of respect that is not the point I was making at all. Certainly I would be interested in the results if I was supportive of the representation made by pharmacy. I make this point again. Here we have four or five business representatives from the world of pharmacy industry prepared to discuss coalface issues with the medical fraternity. So, if the question of good exemplification of NMS or MUR or medicines management or inheriting more medicines led care pathways comes up we have at the ready someone who could offer supportive evidence based examples of outcomes from patient interactions. NO WE DO NOT we have business only representation and not one of the people from Alphega, Boots, Actavis or Pfizer are PHARMACISTS you know the health professional who deals with patients & liaises with GPs. Please understand this Zoe, I am in no way denigrating their abilities or knowledge of the health system in general but the topic here is the frank need for primary care community pharmacists & GPs harnessing better and more fulfilling relationships with an outcome in mind.
Zoe, this delegate list is incongrous, visionless, misleading and if I remain solus with this insulting to pharmacists. Yes it's lovely to feed in questions Zoe but there are plenty of pharmacists out there that should have been offered the opportunity to meet with these GPs in place of the sponsored, cash for questions approach. If the topic was medicines shortages, wholesale dealing, generics, branding, robots in pharmacy yes these delegates are right to get involved but where patients and clinical engagement is the primary issue then pharmacists should be proudly leading this discussion.