The Covid-19 experience has forced rapid change on a normally change-shy NHS. The most obvious example is the use of technology as a replacement for many traditional face-to-face consultations. This has been found to increase capacity in hospitals and is welcomed by many patients.
However, the post ‘wave one’ Covid-19 world has senior NHS managers, particularly in the secondary care sector, scratching their heads as to how they can tackle the enormous backlog of patients waiting for treatment as a result of the suspension of routine activity for many months. Plans to deal with this were barely off the starting blocks before the second Covid wave reared its ugly head.
This article explores the concept of ‘left shift‘ and its increasing importance, and speculates how this offers a new opportunity for community pharmacy to have a significant role in the solutions to these problems.
Conclusio has a long-held belief in community pharmacy as a potent partner within any integrated care system. We also have a history of promoting pharmacy’s potential and ensuring its capability and capacity is understood and built into transformation strategies within a changing NHS.
For many years there has been an overwhelming consensus that there is a need to expand and improve care in local communities and reduce reliance on secondary care, avoiding admission if possible, but at least reducing length of stay in hospital to an absolute minimum. This overarching principle has been coined the ‘left shift’. Unfortunately, as has frequently been pointed out1, the best way of describing progress on this laudable aim is ‘left drift’. Why so?
Every system is perfectly designed to deliver the results it gets and some elements of the NHS system have simply blocked progress. These include:
• NHS financial regime. Payment by results, the tariff system of money following patients, has meant secondary care has not been interested in letting patients go. Each patient arrival in outpatients, planned surgery, in A&E and on acute wards is met with a distant ‘ker-ching’ of the cash register. The patients could move to a community service, but this leaves a foundation trust with the fixed costs of the service and less income. Why would it help that particular move?
• Professional distrust. To be blunt, hospital consultants often believe that only they can safely look after many of their patients. The ego of the specialist plays a huge part in this. Generalists (as community care providers often are) are lesser mortals in the eyes of some of our very senior consultants.
• The ‘too difficult’ pile. Changing services delivered by hospitals is at the top of the managerial ‘avoid at all costs’ league table (and that is a tough league). I know many who are scarred by the experience of facing angry, placard waving mobs in community centres when proposing to move a service from one hospital to another or removed from a hospital altogether during ‘public consultation’. The walk back to the car after these events can be a nervous time. If you do not have real clinicians taking the stage and championing the changes, then forget it. Social media has not made the task easier. It was once suggested on one post that I should be ‘tarred and feathered’, a fate I thankfully escaped – up until now.
• Misplaced public confidence. Have you ever heard someone say, when informed that someone they know is in hospital: ”Well, I’m sure they are in the best place”. They might be if they are acutely ill, require critical care and/or intensive nursing, but the truth is that there are many people that hospital care can actually damage and make more dependent. In some instances, their death is even hastened by the very institutions that are there to look after them.
• Care silos. Care systems have historically not been joined up in any sense of supporting patient/client journeys. Patients have a dreadful time when crossing the boundaries between different parts of the system, particularly between health and social care.
• Restrictive practices. The protection of rigid boundaries between professional groups sometimes resembles the era of Red Robbo and Longbridge and 1970s-style trades unionism2. As George Bernard Shaw, in his 1906 play The Doctor’s Dilemma, wrote: ”All professions are conspiracies against the laity.”3
However, it should be noted that the financial regime has been turned on its head. So-called block contracts are shifting the motivations of hospital leaders. Covid-19 has necessitated reduced hospital footfalls and some of the changes have shown that the roof hasn’t fallen in.
Some of the resistors have now been persuaded. The development of integrated care systems has accelerated and joined-up working between different care leaders has been hugely beneficial – they have all got each other on speed dial. The centre is taking the opportunity to focus performance management at system rather than organisational level.
The shortages of professionals in just about every speciality has led to a focus on ‘top of licence’ working, each profession doing most of the time what only it can do, with some creativity in terms of letting go of some things others can do, and actually finding their jobs more rewarding as a result. A new workforce of talented people are finding rewarding jobs in care. We need to make sure we keep them for their entire working lives by ensuring that they are able to progress into professional roles through routes other than full-time university courses.
So in terms of creating secondary care capacity, how can community pharmacy contribute?
This first thing to remember is that busy managers in secondary care know little of community pharmacy services and what they can offer in terms of giving support to patients. However, anything that can prevent patients attending hospital, facilitates early discharge or monitors patients on an ongoing basis, or which spots or stems patient deterioration and frees up secondary care capacity, should arouse interest and enthusiasm.
The approach will have to be proactive and be led by community pharmacy. Secondary care will not know what to ask you to do; it doesn‘t know your capabilities.
Community pharmacy has long held its place in the NHS through a contractual relationship brokered with primary care commissioners. This relationship has brought dividends, securing the sector as a high street healthcare fixture, but also narrowed the opportunity for community pharmacists to contribute more widely to the challenges that beset the broader healthcare estate. There are signs that this is changing as community pharmacy, through local pharmaceutical committees and others, initiates dialogue beyond primary care, seeking new commissioner/provider partnerships with NHS trusts and community providers.
The advent of integrated care adds more fertile ground for new partnerships to flourish and for community pharmacy, with its huge daily footfall of patients, to be in the vanguard of health system leadership and improving outcomes for patients.
In London, LPCs have combined to determine a pharmacy strategy, London Community Pharmacy – Our Offer to London Pharmacy4 ,which formalises both existing and new service offers. Designed to keep Londoners healthy, it demonstrates a long-term approach that can bring screening, testing, immunisations, long-term condition management and medicines optimisation not only nearer to the patient but also on a walk-in basis. This level of organisation and response is ripe for playing into the issues that nag at trusts.
However, dialogue between NHS trusts and community pharmacy needs an injection of purpose and pace to build partnerships that will truly make a difference to patients.
Bringing this strategy to life and making it real to the key decision-makers at hospital level is a key priority moving forward. Conclusio is currently working with Pharmacy London in supporting the group to develop a new core service offer to local hospitals in London.
Raj Matharu, pharmacist and chair of Pharmacy London, a representative body of London LPCs, says: “The geography of care has changed, with services being provided on a neighbourhood, borough and health system-wide basis. In the new landscape, community pharmacy is responding at every level of provision and keeping people healthy. The sector is developing a new outlook on the partnerships it builds and how it is commissioned for the vital work it does in the community. As we have launched our Pharmacy Strategy 2020, we will be building on our opportunities to forge new working relationships with secondary care.”
He adds: “The extensive community pharmacy network is readily adaptable to provide care closer to home for acute and urgent care and planned care services. Community pharmacists are accessible and trusted by their local communities to deliver services in Covid-19-secure premises.
“The sector is primed to work with partners to jointly develop the workforce and infrastructure to provide innovative services that add value to the patient experience and the NHS. We know we can do so much to help our colleagues in NHS trusts by sharing in their challenges, making them our own and joining them in a common endeavour to improve the experience and outcomes of patients.
”In summary, left drift is at last changing to left shift. This will bring new challenges but also new opportunities, new ways of working, better outcomes and better use of resources. The train is beginning to move. It is time perhaps for community pharmacy to force themselves on board and become an even more vital and dynamic partner in a crisis that demands whole system solutions.”
Mike Proctor is non-executive chair of Conclusio and former chief executive of York Teaching Hospital NHS Foundation Trust, from which he retired in 2019 after 45 years’ service in the NHS.