In AnalysisIt’s time to delve deeper into health discussions. Broaden your understanding of a range of pharmacy news and topics through in-depth analysis and insight.
April saw NHS England delegate much of its commissioning power to integrated care boards (ICBs). Whether viewed as a welcome opportunity or cause for concern, the move has the potential to significantly change community pharmacy and shouldn’t be ignored.
“This is a devolution of healthcare and pharmacy will be disenfranchised if it doesn’t pay attention,” says Ade Williams, lead pharmacist at Bedminster Pharmacy in Bristol.
“Integrated care systems are going to fast become a critical part of the local healthcare landscape for community pharmacy,” says James Wood, director of contractor and LPC support at PSNC. “While the community pharmacy contractual framework will continue to be negotiated and set nationally, these new systems will pick up the administration of this from NHSE locally, as well as overseeing local healthcare priorities.”
At a local level, he says the introduction of ICSs will mean a simplification of commissioning organisations. Local pharmaceutical committees have been evolving alongside this to be best equipped to play a part in ICS work, supported by PSNC, he says.
An ICS is about “the whole of health and social care coming together to decide on priorities and deliver on the needs of its population”, says Ewan Maule, director of medicines and pharmacy for North East and North Cumbria ICB, and a member of the RPS English Pharmacy Board.
“The ICS will decide the strategy and the board will deliver on that strategy. That means ICBs are not just an amalgamation of the previous CCGs – although they are taking on those functions as well – but are broader organisations with a new, refreshed remit and mandate,” he says.
Whereas under CCGs community pharmacy “often felt left out from local thinking; that is something that should start to change under ICBs”, says Maule. “There is a chance to be a more integrated part of a whole system approach to primary care – something that has previously been quite difficult for pharmacy.”
In the past, he says, community pharmacy had to make its case to NHS England, while general practice was making its case to CCGs. “This meant that the thinking about what primary care could deliver wasn’t necessarily always as joined up as it should have been, and as localised to the population as it might have been. There is a real opportunity for community pharmacy now.”
In the short-term, he adds, “the people in NHS England that community pharmacy has been dealing with will either become aligned to, or transition across, to ICBs”. However, what will ultimately change is how services are commissioned.
“For example, our ICB has commissioned a community pharmacy urinary tract infection diagnosis and treatment service. This shows how a joined-up system approach means that pharmacy can propose alternative service models that take advantage of its unique place in communities and the ease of access that offers.”
This is a devolution of healthcare and pharmacy will be disenfranchised if it doesn’t pay attention
LPCs will be supporting community pharmacies through the changes concerning how services are commissioned. Julia Powell is chief executive officer on behalf of East Sussex, West Sussex and Surrey LPCs. There are six ICBs within the south-east region, which were early adopters of the new devolved set-up, taking on the management of community pharmacy, dentistry and optometry from NHS England last July.
Since then, she says, “we have seen much greater recognition of community pharmacy as part of primary care and, as an LPC, the number of committees and groups we are involved with has doubled, including those focused on conditions such as cardiovascular disease and respiratory care. This has enabled us to demonstrate how community pharmacy can be involved in different pathways. There is also a greater recognition of what community pharmacy is already doing, such as the hypertension case finding service”.
Community pharmacy integration leads are also helping the sector’s transition to ICSs. Funded by NHS England for two years, these posts have been “well received within ICBs and become very busy, very quickly”, says Ewan Maule. “They have an important role in the ICB and I hope others take the same approach. It is effectively providing the link between community pharmacy and ICBs.”
With community pharmacy moving into ICBs, “there are real opportunities”, says Michael Lennox, the NPA’s local integration lead and chief executive officer of Somerset LPC. “However, it is not without risk. If we don’t get the landing and trajectory right, it will be difficult to recover course.”
His hope is that, “if our contract is delegated into an ICS, then surely it is going to be owned by that ICS, and it is going to be cradled and cared for at the heart of the delivery of healthcare. We haven’t had that before – we’ve been at a distance from the heart of health systems. If our contract is cradled, this means that the functions, the finances and the forms in which we deliver will be much improved, and we will actually be part of the ecosystem at a leadership and delivery level.”
Integrated care systems are going to fast become a critical part of the local healthcare landscape for community pharmacy
Raising pharmacy’s profile
With the shift to ICBs locally, Ewan Maule says pharmacy needs to make sure it is at “the front of the queue during the lifespan of ICBs as we won’t get another opportunity like this to really raise the profile of pharmacy in the system. We have to take advantage of it”.
Another benefit of the move to ICBs is that they have “not just an expectation, but a requirement to demonstrate multi-professional care and clinical leadership”, he says. “Pharmacy should be front and centre of that clinical leadership and grasping that opportunity.”
One of the ambitions of ICBs is to tackle health inequalities – and pharmacy can play an important role in this, he says. “We know that all sorts of different patient groups can feel excluded from planned care and care where appointments are needed, including general practice. Lots of people find community pharmacy more accessible, and because of ICBs’ desire to address health inequalities that is a real positive for us,” Maule believes.
Ade Williams says ICBs present opportunities to do more in terms of patient health management. “If pharmacy gets it right, we will become a bastion of population health management delivery across multiple clinical indications, while also becoming the ‘go to’ health equity champions.”
At a time when every area of the health service is under pressure, “I hope ICBs mean there are going to be better relationships, and a better role and respect for community pharmacy – that we are seen as part of the primary care solution and not ignored,” says Lindsey Fairbrother, owner of Goodlife Pharmacy in Hatton, an independent contractor, and regional representative, North and East Midlands, PSNC.
ICBs are not just an amalgamation of the previous CCGs – although they are taking on those functions as well – but are broader organisations with a new, refreshed remit and mandate
Challenges and risks
Along with the benefits and opportunities ICBs could bring for pharmacy are some challenges and risks. “Community pharmacy has its own pressures – workforce being the most challenging of these. A concern is that even if these opportunities for new services and different ways of working arise, does community pharmacy have the resilient workforce to deliver on them?” asks Ewan Maule.
There is also the risk that delegating the commissioning of pharmacy services to ICBs may be in name only and that, while tasked with looking after the pharmacy contract, “in reality [ICBs] may not grasp it and make a difference with it”, says Michael Lennox.
For LPCs working with more than one ICB, “one of the challenges could be that they may have different agendas and priorities”, says Julia Powell. “It is also important to ensure we work within our own community pharmacy contractual framework, and that any expectations or requests that sit outside of that framework are either appropriately remunerated or it is articulated that they are not within our remit.”
I hope ICBs mean there are going to be better relationships, and a better role and respect for community pharmacy – that we are seen as part of the primary care solution and not ignored
Having a voice
As community pharmacy doesn’t have a statutory place at the ICB table, there are concerns that it won’t have a voice in the key decisions affecting pharmacists and their patients. “A lack of dialogue [over new services] has always been a challenge for us. Pharmacists need to be part of the discussions taking place locally about commissioning and policies,” says Lila Thakerar, superintendent pharmacist at Shaftesbury Pharmacy in Harrow.
“I would like to see communication with the ICB on a regular basis and continual conversations about services. My concern is that we are not going to be heard. We are at the forefront of providing patient care, and we need to have some say in how that care is given and the funding that will help us provide it,” she says.
Prioritising the health needs of a population in a specific ‘place’ or ‘neighbourhood’ (see panel) “could mean significant divergence of services in different locations”, says Paul Day, director of the Pharmacists’ Defence Association. “That could be more of a challenge for multiples seeking standardised operations across larger geographies and be an added complexity for locums working in many locations.
“However, this is not insurmountable and those who have operated across borders between devolved governments are already used to differences in provision.”
While more additional and advanced services might be created under the new system, a challenge for pharmacy will be having to compete against other suitable providers to deliver those services. “Lots of organisations sit at the ICB table – general practice, local authorities, public health teams and third sector organisations. A key question will be: ‘Can pharmacy do this better than anyone else?’,” says Ade Williams.
Community pharmacy is on a journey and contractors need to come with their LPC leadership on that journey. They are the key to getting this right on the ground
“Once in a generation opportunity”
Faced with these opportunities and concerns, what is vital to remember is that “this is a once in a decade – possibly once in a generation – opportunity to put pharmacy front and centre of the new NHS”, says Ewan Maule.
“That is going to take collaboration and leadership at local, regional and national level, so my message to community pharmacy is find out what is happening, and how to get involved and engaged, and support that clinical leadership.
“While it is easy to be cynical, it is fair to say this change is different and a much greater opportunity for pharmacy than there has been before,” he adds.
“Community pharmacy is on a journey and contractors need to come with their LPC leadership on that journey. They are the key to getting this right on the ground,” says Michael Lennox.
“Engage with your LPC to see what they say is changing – find out what is happening on your patch,” advises Lindsey Fairbrother.
“We need to be involved and we need to be very proactive in making decisions for the ICBs and with the ICBs,” agrees Lila Thakerar. “If not, then there’s a loss of many years of experience and, most importantly, patients lose out as well.”
For Ade Williams, the hope is that ICBs will help to advance the role of community pharmacy and secure its place locally. But his fear is that “ICBs have not recruited individuals who understand community pharmacy’s potential, and we don’t have the people bringing forward that case ourselves. ICBs need people who ‘get’ what community pharmacy is saying; we need to have the best people doing the same for us.”
That said, the changes are not going to be revolutionary, Williams believes. Rather, the sector is at the start of an evolutionary journey – and pharmacy needs to know what’s going on.
The new system explained...
Integrated care systems (ICSs) are where health and care partners come together at scale to set overall system strategy, manage resources and performance, plan specialist services, and drive strategic improvements in areas such as workforce planning, digital infrastructure and estates. There are 42 ICSs across England covering populations of around 500,000 to 3 million people.
Integrated care boards (ICBs) are statutory bodies responsible for planning, funding and arranging the provision of most NHS services in a ICS area.
Integrated care partnerships (ICPs) are statutory committees that bring together a broad set of system partners, including local government, the voluntary, community and social enterprise sector (VCSE), and NHS organisations, to develop a health and care strategy for an area.
Neighbourhoods (covering populations of around 30,000 to 50,000 people*) are where groups of GP practices work with NHS community services, social care and other providers to deliver more co-ordinated and proactive care, including through primary care networks (PCNs) and multi-agency neighbourhood teams.
Places (covering populations of around 250,000 to 500,000 people*) are where partnerships of health and care organisations in a town or district – including local government, NHS providers, VCSE organisations, social care providers and others – come together to join up the planning and delivery of services, redesign care pathways, engage with local communities, and address health inequalities and the social and economic determinants of health.
*Population sizes are variable
Source: King’s Fund. Integrated Care Systems Explained (2022)