Going local for a change
With a national contract, there has been little enthusiasm for effecting change through community pharmacy at a local level, and a lack of agreement about whether such developments are either desirable or practical. However, some local pharmacy leaders have seen increasing NHS localism as an opportunity, and have been exploring the options.
Blame Andrew Lansley. The Health and Social Care Act of 2012 fragmented the NHS in England, created hundreds of new organisations, and signalled an end (for the time being) of major national development of service and contract models. The Five Year Forward View (5YFV), published in 2014, sought to energise the NHS by breaking down barriers across the system, including between health and social care.
It introduced new models of care, locally developed and sensitive to community needs. Every local health and care system was challenged to create a plan for accelerating implementation. The Sustainability and Transformation Partnerships (STPs) that created these plans across 44 English localities, were supposed to improve and co-ordinate services. They, in turn, are being supplanted by more advanced Integrated Care Systems (ICS) in some areas. In the biggest deal of all so far, huge areas of public provision have been devolved in Greater Manchester to its local authorities and health service equivalents.
To community pharmacy, this might seem irrelevant – the NHS has undergone countless reorganisations in the past, and community pharmacy is under enough pressure as it is. There is little time to think about whether these changes have any impact, let alone do something about them if they do.
The pharmacy cuts and the multi-layered attempts to remodel care have the same roots. The £30bn five year funding gap identified in the 5YFV and the workload crisis in general practice are prompting different thinking at all levels, be they STP/ICS, Clinical Commissioning Group (CCG), or new groupings based on populations of 30-50,000, such as Primary Care Home and Primary Care Networks.
There are signals these principles are going to stick. The cost and chaos of the Lansley reforms has left little appetite for further restructuring, and while governments of all stripes have put off fixing the stand off between health and social care, the day of reckoning must be nigh.
NHS chief executive Simon Stevens has described STPs as “the only game in town”, while the move of major NHS figures like former trust chief executive Sir Andrew Morris into integrated care suggests the current approach has some way to run.
The workload and workforce pressures on general practice are forcing change too. The natural career ends of the ‘60s cohort of GPs and the early burnout of their newer colleagues comes at a point of escalating demand.
GP average weekly contact hours are down as more shun the principal model in favour of more flexible, session-based duties. Practices are merging or federating, or being run by third parties. New models of primary care led by GPs, but encompassing a wide range of professionals, are spreading. Primary Care Home, pioneered by the National Association of Primary Care, claims over 200 sites covering seven million people. NHS England’s Primary Care Networks are essentially the same thing.
For community pharmacy, the challenge is twofold. Philosophically, it’s a national service, and while medicines remain the second largest budget item and the dominant form of treatment within the NHS, pharmacy has rarely been at the centre of efforts to reshape care. From fundholding to commissioning, and CCGs to Health & Wellbeing Boards, community pharmacy has always found itself on the periphery, and begging to be heard.
However, there are signs here too that at a local level, the barriers are at last starting to come down, with examples of closer collaboration with community pharmacy across the country at regional or STP level, at CCG level, within Primary Care Home sites and even at practice level.
The challenge is being met head on. Michael Lennox, chief executive, Somerset LPC, says after following through for three years, things are starting to happen. “Trying to leverage the status quo is not working for anyone,” he says. “It’s important to work with the grain of what’s going on. You need to become part of the system.”
That’s a view shared by Adam Irvine, chief executive of Greater Manchester LPC. “The creation of a mental health and care community across the Manchester city region has brought some interesting elements together. We have medicines optimisation and council care teams working together, which means discussions based on ‘this is what we are thinking, and why’,” he says. ‘DevoManc’ feels different. “It’s important to get relationships to a place where you can co-create. We had a year figuring out what we could do, a year planning what we would do, and now, year three, we’ve started doing.”
Fragmentation means local leaders have to look in lots of directions at once. Ruth Buchan at Community Pharmacy West Yorkshire says: “It’s like backing lots of different horses, but we might miss something potentially useful if I’m not there. GPs and CCGs are not going to be our advocates.” Nottinghamshire LPC’s Nick Hunter agrees. “I’m sick to death of talking about HLP,” he says. “We have footfall of 35,000 and tens of thousands of interventions every day, but people can’t get their heads around pharmacy because problems like delayed discharge take up all their brain space.”
Finding like-minded people on the other side of the table is vital. Nick says his Local Professional Network chair Sam Travis, clinical leadership adviser at NHS North Midlands, is really proactive. “The LPN is still going, everyone’s engaged. She’s good at accessing pots of money. If you add it up, we’ve got the best part of £300,000 going into community pharmacy across Notts and Derby,” he says.
Testbed for wider impact
Local relationships can pay off spectacularly. Rekha Shah, chief executive at Kensington, Chelsea & Westminster LPC, says the London flu service success was built on the relationship the Pharmacy London flu team had with commissioner Kenny Gibson. “Kenny’s view was that you just needed to be organised,” she says. Asked once whether pharmacies could vaccinate commuters, his answer was simple: “This is a service for London. They’re in London.”
His enthusiasm to use pharmacy to improve cover saw the service spread far and wide. “Kenny allowed anybody who cared for someone in a key group to get vaccinated,” Rekha says. “We went out to London Ambulance staff, the Fire Brigade, NHS111 staff, district nurses. Kenny’s view was that we should avoid flu causing important services to fail.”
The success of the London flu service built confidence for a national service, although some things have been lost in London as a result. And Gibson’s promotion to a national safeguarding role means they are unlikely to be replaced with a local bolt-on, as they might have been had he still been around. Rekha says the sheltered accommodation and wider domiciliary provision have been lost, as has the service for primary care staff and the homeless, other than those with a long-term condition. “The people left don’t understand the ramifications like Kenny did,” she says.
The activity does have a legacy, however, with seven pharmacies in seven boroughs piloting a hepatitis C mouth swab screening service. Iterations of the pilot will see blood testing to reduce the need for acute appointments and then, if successful, a test and treat service too.
Beacon for joint work
The Beacon medical practice in Ivybridge and Plympton (registered population 39,000 across five sites) is entering the third year of its collaboration with local community pharmacies to improve flu vaccination rates at practice level. According to practice manager Claire Oatway, non-attendees at surgery flu clinics in the first year were sent tokens for flu jabs in local pharmacies, rather than a follow up letter, resulting in a 5 per cent increase in uptake. In year two, GPs and pharmacists had a “shared ambition” to target vulnerable patients of working age. “We moved our respiratory cohort vaccination rate from 39 to 53 per cent in the first year of joint messaging,” she says. A competitive element between the Plympton and Ivybridge sites boosted rates further.
The Beacon model has parallels in Manchester. “We have green shoots on flu,” says Adam Irvine. Two practices, one previously high performing, one not, are working with their local pharmacies, targeting COPD patients to start with. He says a lot of mistrust stems from GPs overestimating the scale of the pharmacy service. “In GM, pharmacies did an average 250 flu jabs last year. Our best did a thousand. Once you quantify the threat, they see you as a more helpful partner.”
Success inspires trust
Back in Devon, Beacon are building on the flu collaboration with the creation of a virtual team for long-term conditions. GPs and pharmacists have been working together to improve asthma care. Practice senior pharmacist Robin Conibere says they have built on community pharmacy’s current services. “Yes, they do medicines use reviews (MURs), but we’re getting them to do a bit extra, by asking some questions related to the GP Quality Outcomes Framework.”
Pharmacies have been issued with a target list. “These are patients who aren’t coming into the surgery for their normal reviews,” he says. Of 813 patients, community pharmacists in five pharmacies have covered 120 with MURs in the first five months. WhatsApp messaging about the project has become an informal contact group across practice and pharmacies, building the sense of team working.
Success at Beacon has been the basis for action elsewhere. David Bearman, Devon LPN chair, says money from Health Education England has been used for interprofessional learning for GPs, nurse practitioners, pharmacists and paramedics. “Relationships are key,” he says. “Behaviours and trust are the building blocks for any transformation.” Down the road in Plymouth, another small sum was used to bring surgeries and pharmacies together to discuss making each other’s lives easier. The result? “In the first few weeks new medicine service (NMS) levels went from 50 a year to five a day,” David says. “For £15k, we got implementation worth £10k per pharmacy”. And better care. “I wanted them to talk about repeats, but they never got to that. Pharmacists want to do more. This is more rewarding; even busy pharmacies are making time.’
At the other end of the country, GP practice pharmacist Chris Roberts is integrating the six pharmacies in Fleetwood into a COPD screening service. “The town has 30,000 people; we have 1,000 COPD patients in the registered population. The evidence suggests we should have more,” he says. Pharmacies will screen, refer for spirometry, manage the first prescription and follow up. The programme, which has support from pharma, will run for 18 months. “We want to integrate pharmacists into our practice work more,” he says, adding that pharmacy access to GP system EMIS has been provided.
Elsewhere, progress can be slow. “We’re standing still,” says Lincolnshire LPC’s Steve Mosley. “Two of the four CCGs have had inquorate meetings in the last three months, so there’s no chance.” The minor illness referral service pioneered in the North East goes live soon, but he does not believe NHS England has the capacity in the area to land it properly. “Nothing will happen without a serious attempt to shift patient flow,” he says.
For Nick Hunter delivery is an issue. “People are struggling to keep their heads above water.” Short-termism doesn’t help. “We’re just kicking off a blood pressure/atrial fibrillation campaign,” he says, “but if lots of pharmacies get involved, it might only last a couple of months. A PGD addition to our minor ailments scheme was due to end this month; now it’s been extended to the end of March.”
Michael Lennox remains upbeat. “If I can’t do something really positive over the next 12 months I’ll be really disappointed,” he says. “Prevention and long-term conditions are OK, but if we can do something in the acute area it’s going to be sustainable.” He’s working with the local NHS111 provider to support GP out of hours using community pharmacy. Selfcare, urgent medicines, post-discharge reviews are all on the table. He says: “If we do it well we will be in a great position to ask ‘what else do you want us to do’. And once it’s out of the GP sector it will be difficult to put back in.”
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