Opinion: One primary care contract for all?

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Every now and then, I find myself reflecting on the years I spent in amongst the higher echelons of policy-making. I didn’t make policy, of course. My role was to advise.

One observation that will come as no surprise to anyone is that primary care policy was overwhelmingly about general practice. 

During most of my time, the other three contracted providers – dentistry, optometry and community pharmacy – were very much the minor players in the minds of policymakers. These things take time to change, and community pharmacy policy has chipped away at the dominance of general practice. 

As general practice started to become overwhelmed with demand, diversification became more likely, and resulted in the provision of vaccinations and more clinical services in community pharmacy. But where community pharmacy always dominated was medicines supply. Indeed, in policymakers’ minds, the primary role of community pharmacy was to ensure patients got their medicines. 

Clinical expansion

One could argue that on the one hand, this policy bias towards supply has helped patients and contractors. On the other hand, it portrayed community pharmacy in policymakers’ minds as a commercially driven supply enterprise, holding back the sector’s clinical development.

Again, this is changing, as supply becomes more efficient with the long overdue introduction of hub and spoke dispensing across corporate bodies and as clinical services such as Pharmacy First expand. 

“The last thing needed is clinical competition between sectors”

However, if someone took a long, hard look at the provision of primary care, they would see competition between different sectors driving lack of coordination and collaboration, and sometimes inefficiency too.

The forthcoming massive expansion of pharmacist prescribing could make this worse, so policymakers are – I hope – considering how integrated NHS services can become the norm. Otherwise, not only will NHS care become more disjointed, but private healthcare provision will become community pharmacy’s future. So how can integration happen? 

Separate supply and services?

Policymakers often talk about the levers at their disposal, such as regulation and incentives. I ask myself if the integration necessary to provide safe and joined-up patient care can be achieved by tweaking the various forms of regulation or paying providers to do things differently. 

Digitisation will help as patient records become more unified and accessible, but in my view, competition will remain and be a driver of division. Something more fundamental needs to happen. 

The late great Bill Scott, the former chief pharmaceutical officer for Scotland, and I often used to discuss how we could split the community pharmacy contractual framework, separating supply from clinical services. 

We had some allies within the community pharmacy world and beyond, but we never got there because the right conditions were not in place. The financial and business conditions necessary to ensure contractors could make a reasonable living were largely absent, and policymakers still saw supply as the priority for high street pharmacy.

Prescribing and centralised dispensing are two important levers that could lead to more opportunity for separation of supply and clinical services. 

Let’s have standardised care

Let’s take a clinical example – hypertension. 

There is real scope for duplication and confusion between who does what in community pharmacy and general practice. The last thing needed is clinical competition between different sectors, with the public confused. 

Instead, let’s have one hypertension service across primary care, with a standardised clinical pathway setting out who does what and when, underpinned by one contract. Once that has been demonstrated to work well for patients, taxpayers and providers, let’s move onto other single contracted clinical services across primary care, such as asthma or diabetes. 

As for medicines supply, there is likely to be a need for rapid access to some medicines and that is likely to remain in the purview of high street community pharmacy for some time. But for long-term conditions, the contract for supply could be very different and rest largely with dispensing hubs. 

Some would say that this is more ‘Ridge heresy’ but we all know this is likely to be on the minds of many – whether they are policymakers, contractors or advisers. The question is more when not if, so discussing it openly and testing how it might work most effectively for patients and providers, while still providing value for money, is the wisest next step.