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The interview

Looking forward, talking up

In turbulent times for pharmacy, one man has often been the focus of community pharmacists' ire. But Dr Keith Ridge stands steadfast in his commitment to clinical pharmacy and the standards he says will define it. And NHS England's chief pharmacist was talking pharmacy up when he sat down with Rob Darracott.

If the chief pharmaceutical officer for NHS England has a masterplan, then it exists in the form of the 2008 Government White Paper Pharmacy in England Building on Strengths - Delivering the Future.

Extremely well received at the time, and written around two years after Keith Ridge rejoined the Department of Health as chief pharmacist, it included a programme for action that ranged widely across the professional landscape. Healthy Living Pharmacies are in there, as is the promise of what was to become the New Medicines Service. There was going to be closer working between GPs and pharmacists, action to establish the General Pharmaceutical Council, pharmacist prescribers as the norm, and changes in education and training to help ensure that pharmacists had the clinical competencies to deliver the types of services needed by the NHS in the future.

Interestingly, it contained the concept of a "health community clinical pharmacy team", which certainly resonates with the thinking around the development of primary care networks (PCNs) launched by the NHS Long Term Plan. But it also highlighted concerns with medicines, including rates of non-adherence to treatment and hospital admissions related to adverse effects, which are still referenced today, more than 10 years on. These were accepted in 2008 as issues for pharmacy to act on, and the investment in practice-based pharmacists could be represented as the centre finding a different route to finally focus the profession to make progress.

So when I met up with Dr Ridge in the middle of March, I started with that White Paper, which held so much promise, and actually delivered a lot in the short time before the 2010 election put paid to the Government that backed it. I suggested we hadn't made the most of that masterplan, if that's what it was, given the collective sense of forward movement it had on its launch. "That's a good read," he says. "The 2008 White Paper was a landmark. I was thinking at the time, and other people were involved, how things might pan out in primary care, in general practice particularly, but including in community pharmacy. How you could link together the issues around medicines and their use. The evidence base was emerging then; and we now know what the issues are.

The masterplan is obvious, really, which is to have clinical practitioners, in this case pharmacists, supported by clinical pharmacy technicians, working as part of a multi-professional team.

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"The masterplan is blindingly obvious, really, which is to have clinical practitioners, in this case pharmacists, supported by clinical pharmacy technicians, working as part of a multi-professional team. If you think of a ward round in a hospital, you've got, typically, a consultant medic leading a team of professionals, nurse, clinical pharmacist, the physio, and so on. If you translate that into primary care and pull it across a primary care network - the PCN is a gamechanger - then you create this multi-professional team, led by a clinical director, typically a GP, of competencies which are needed to be able to bring work out of hospitals, and deal with the complexity that's required. "

"You could argue that the 2008 White Paper was the beginning of that, in terms of Government policy." He brings up HC88(54), the Department of Health circular which was principally responsible for the development of clinical pharmacy in hospitals more than 30 years ago. "Where we've got to with the deployment of clinical pharmacists across primary care networks is as significant in pharmacy policy development as that. The White Paper was an important document. Nobody had done that sort of thing before; some of it was implemented, and in many ways we are continuing to implement it. But it's now the NHS Long Term Plan which is the shape of the future and that's where we are going."

I suggest that the use of the term ‘clinical pharmacist' in hospitals and the 1980s was important in gaining acceptance, by doctors in particular, of pharmacists operating outside of pharmacy itself, as ward-based clinicians. He pauses. "One thing I have learned, having done this job for a while, and I know it is easy to say, is that things take time. You look at innovation generally, and it's, you know, 15 years… But HC88(54) was essentially rubberstamping things which had developed over the previous 20 years. Now we are in the same sort of situation. We started it in terms of clinical pharmacy in general practice. But with the changing evidence base around complexity and issues associated with medicines, what the Long Term Plan is doing is accelerating it with the deployment of five or six clinical pharmacists across each of around a thousand primary care networks. We're committed to it, and in a way which is funded, in terms of salary, through the GP contract. It's done."

I want to get to where he sees community pharmacists fitting into all of this, particularly given all that has happened over the last three years, but Dr Ridge wants to start with another area he has been closely associated with for more than 10 years - education, training, the role importance of standards, and the demonstration of continuing competence.

"We've got an 18-month training pathway for clinical pharmacists. That has essentially created a standard. If people wish to become clinical pharmacists within primary care networks, then they too have to meet that standard. This is the opportunity to regularise it properly, because demand for those clinical skills is markedly increased; the public and patients are becoming increasingly reliant on those people. We have a duty to make sure people are trained appropriately.

"We've set the standard as the 18 month training pathway. I chair the pharmacy subgroup of the clinical workforce group set up to develop the people needed to deliver the Long Term Plan," he adds. "A consistent, high quality, foundation training for all pharmacists is right in the heart of that."

  1. March 2006
     
  2. April 2008
     
  3. December 2009
     
  4. September 2010
     
  5. April 2011
     
  6. October 2011
     
  7. April 2013
     
  8. October 2014
     
  9. July 2014
     
  10. December 2015
     
  11. December 2016
     
  12. July 2017
     
  13. December 2017
     
  14. January 2019
     
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Dr Keith Ridge joins Department of Health as chief pharmaceutical officer

White Paper Pharmacy in England, Building on Strengths, Delivering the Future

NHS Portsmouth publishes first Healthy Living Pharmacy model framework

General Pharmaceutical Council is established as the independent regulator for pharmacists and pharmacy technicians

Modernisation of Pharmacy Careers proposal for integrated five year degree programme for pharmacist formation accepted by Medical Education England (predecessor or Health Education England)

New Medicines Services (NMS) launched as part of community pharmacy contractual framework

Dr Ridge joins NHS England as chief pharmaceutical officer post transfers as part of Health & Social Care Act 2012 implementation

NHS Five Year Forward View (5YFV) highlights health and wellbeing, care and quality and funding and efficiency gaps; introduces (local) new models of care programme to test new approaches; highlights potential for greater use of pharmacy and pharmacists

First wave of general practice pharmacist posts launched, with a focus on medicines-related patient consultations, co-morbidity and long term conditions

Community Pharmacy in 2016/17 and Beyond letter introduces funding reforms as part of the funding and efficiency challenge in the 5YFV, and launches Pharmacy Integration Fund

National pilot of the community pharmacy urgent medicine supply service commissioned as an advanced service (NUMSAS, currently commissioned to September 2019)

Second phase of GP pharmacist scheme takes total numbers of pharmacists in practices to well over a thousand.

Digital Minor Illness Referral Service (DMIRS), based on referrals from NHS 111, begins piloting in North East, using Integration Fund monies. A further pilot, with referrals direct from GP practices, will begin in 2019.

The NHS Long Term Plan sets out plans for joined up care based on the practical experience of the 5YFV new care model pilots and with a major investment in primary care, including the development of integrated teams of clinicians, serving populations of 30-50,000 in primary care networks.

No bar to involving community pharmacy

We get to community pharmacists. He's positive, but direct. "There is no reason at all why community pharmacy could not be part of the provision of clinical pharmacists across primary care networks," he says. There's a slight pause. "But they have to meet the standard. That's it. It's only right from a public safety point of view." You can see why suggestions community pharmacists might self-certify as competent prescribers gets short shrift.

"Ultimately the whole thing joins up through system leadership, and that's the pilot we are doing across seven regions (Sustainability and Transformation Partnership and Integrated Care System level) at the moment. I'm currently proposing the appointment of what I'm calling directors of pharmacy and medicines. I hope that has been accepted in principle." He accepts this seems a little bit command and control, but as he continues I see a closer parallel with the old district pharmaceutical officer roles that disappeared in the 1990s. "You get line of sight from the function I currently occupy, through the regional pharmacists, linked with the 44 ICS/STP pharmacists to the front line of pharmacists in practices, across PCNs, in hospitals and in community pharmacy. A proper approach to clinical service provision. That's the plan."

Dr Ridge says the recent GPhC consultation on initial education and training was very important. Again, we're back to that White Paper. "We looked at how best to do that in the Modernising Pharmacy Careers programme. We got caught up in the changes to education policy, but it is now back on the agenda. We need to make sure the clinical future is underpinned by appropriate education and training."

It's now the NHS Long Term Plan which is the shape of the future and that's where we are going.

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In 2008 the national bodies community pharmacy bodies were very much on the same page as the Department of Health; the Healthy Living Pharmacy programme kicked off in Portsmouth shortly after publication, the New Medicine Service arrived in 2011. I ask about the current situation. "At representative body level, we agree that the future of pharmacy provision, irrespective of location, is clinical. When I visit pharmacies, and I remember one recently, the pharmacist there was just fantastic." He brings up the debate about the terminology. "She has no doubt she is a clinical practitioner. She might think, rightly, ‘well, surely I'm trained enough to do [the PCN clinical pharmacist role]', but there's a discussion to be had about the existing workforce as a whole, what they are doing, and whether they all meet the standard or not. That's irrespective of whether they are in hospitals or in general practice, or indeed in community pharmacy."

Dr Keith Ridge explains to P3's editor Rob Darracott that "this time we have all got to work together to get it absolutely spot on. And that won't happen overnight, it's going to take time to get it right."

Sometimes the customer doesn't want to buy

He accepts that there are probably people who are not quite there yet. "One of the things that has come out of the last three years is a lot more understanding that the NHS is the customer here, and whilst community pharmacy may want to provide a range of new services, sometimes the customer doesn't want to buy those. For example, it makes clear in the Long Term Plan that the most important clinical service for community pharmacy for the next period of time is the digital minor illness referral scheme (DMIRS), where we are about to go into pilots of GP referral to community pharmacy. That clinical service needs to be delivered to the right quality, consistently, because it has the potential to be enormous for the public and for patients."

He says immediately the progress is subject to contract negotiation. "I'm not really involved in that," he adds, quickly. "We are already on the road to rolling that out with 2,000 pharmacies signed up, and we are learning from the evaluation as it goes on but, subject to the negotiation, it will be rolled out. Put that together with NUMSAS [the NHS urgent medicine supply advanced service], get it right consistently at high quality, together with elements of prevention, and that for me is enough for the present time."

This then, is the challenge for community pharmacy as a whole, but he continues. "Then, at the same time, if community pharmacy wants to do it, think about the extra training required in order to get into the provision of clinical pharmacists across PCNs. Community pharmacy will still need to be networked into all of that, but the question for debate is will community pharmacy want to provide clinical pharmacists meeting the right standard? But in the meantime, get the minor illness service spot on. It's got to be high quality, and it's going to rightly focus the attention of patients in a different way. GP referral to community pharmacy, together with NHS 111 referral, is immense. It's going to become a very high profile NHS service which needs to be delivered to the right consistency. And that's a big programme of work."

There's a discussion to be had about the existing workforce as a whole, what they are doing, and whether they all meet the standard or not.

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I suggest that message is important, but that a similar one issued around the implementation of the New Medicine Service was not acted on in the way it might have been. "I think on NMS you're right," he says. "It could have been done better, to be frank. The evidence base around NMS is strong, and there is scope to learn from how those things were implemented, and if this is going to be front and centre of the NHS, then it needs to be done well in a programme management type of way. Strategically, for community pharmacy, colleagues need to understand that.

"This is going to sound harsh, but this is not a game. And this time we have all got to work together to get it absolutely spot on. And that won't happen overnight, it's going to take time to get it right. The public and many patients are going to be dependent on it. And it's got to be right."

I suggest the last few years have been difficult, to say the least, for community pharmacies in England. Dr Ridge has been the target for many who blame him personally for the way community pharmacy has been dealt with for the past three years. He wants to look forward. "The Long Term Plan is very different," he says. "People are conscious of the financial constraints, and how they reflect on that and whether it will influence how things work out in the negotiations, I don't know."

He does want to talk about automation, though. "People are aware that community pharmacy is changing, but there is scope for further efficiency, of course there is. We need to work with the sector to ensure that the model that is developed around automation is open to everybody, and isn't just narrowed down to particular players. And, as I have said all along, I would hope what it does is free up clinical staff to do the things we are talking about, and to provide the quality and types of service I suspect they want to provide. "One can imagine the scenario where DMIRs is rolled out to a very high quality, in a system where automation that everyone is happy with is open to all. From an individual patient point of view, they can get more access to the clinical people we want them to have access to?

"The timing of all this is beyond my days I suspect, but you could see a really, really positive future for community pharmacy, there's no doubt about that, because you will have an efficient process of supply, the minor illness referrals properly and consistently delivered, and at the same time people trained to the standard I have mentioned to deliver pharmacy services. There are, as you know, some regulatory issues to be sorted out in all this. That's why it's essential that the sector, the Government and the NHS work together on this."

A new commission

The chief pharmacist is in an upbeat mood, in spite of the hours he's been putting in over Brexit in particular. I ask what's next for him personally. "The Secretary of State has asked me to carry out a review of over-prescribing and we're committed to report in 2020," he says. "We've done quite a bit of thinking, in the context of Brexit to be honest, and there is a range of things to consider, but you and I and others have spoken about inappropriate polypharmacy for a number of years. I have been to Canada to look at the work around deprescribing, NICE is now starting to consider the Canadian work, so I just think we are at that point where you can't have a more public expression that there is something to be addressed here. And the Secretary of State has asked someone to do something about it, and in this case, that's me.

"I've been reflecting on that for a bit, because this is not just about pharmacy, this is about a range of professions. It's about the public and their attitudes to medicines, it's about the system in which you end up on a lot of medicines which perhaps aren't always needed, including the approach to medical practice.

"We will look at alternatives to medication, so we are linking with the whole programme of work around personalised care in NHS England - the clinical lead for that is Alf Collins - and he and I are talking about social prescribing. It's a really important piece of multiprofessional work, which I'm very pleased to be heading up."

We are meeting before the first Brexit deadline, so I have to ask. "The NHS, and indeed Government, has to plan for every eventuality. That's what you'd expect, and indeed that's what we are doing," he says. "We have been planning for a significant period of time for a range of scenarios, including no deal. Line by line analysis of the supply chain.

"Community pharmacists and pharmacists broadly are going to be on the front line, so a couple of things to say. Firstly, a big thank you for the work they do. They will be in the right in position to advise the public on how to manage this. It is critical that there is no local stockpiling, because you know what the potential impact might be. I know the RCGP chair Helen Stokes-Lampard has written to GPs about pressure from patients to write longer scripts. Monitoring around all of this is increased. I'm not saying we won't get shortages. But all the transport arrangements the Department and Government have put in place are robust."