As the biggest reforms to general practice in 15 years begin, the next year will be critical for community pharmacy, says Simon Dukes. The PSNC chief executive talks to Neil Trainis…

"I think it’s wrong to compare GPs and community pharmacists,” Simon Dukes says as he ponders what the PSNC should be striving to achieve from its contractual negotiations after watching the government hand general practice a five-year contract.

As the Conservatives’ GP-centric community-based healthcare reforms, supported by what NHS England (NHSE) provocatively terms ‘clinical pharmacists’ - or pharmacists based in GP surgeries - move forward, there is the unsettling sense that as ministers push ahead at pace with their vaunted long-term plan, they are procrastinating on the long, drawn-out proposition for community pharmacy.

Alas, community pharmacy funding talks are yet to begin nearly a year after the government said it would open discussions on shifting the contractual framework from dispensing to services.

Simon, who took over the reins as PSNC chief executive from Sue Sharpe in May last year after five years as CEO of the fraud prevention service Cifas, is adamant “the sheer weight of Brexit-related stuff has impacted” on the government’s “ability to do other things.”

In a quiet room in the PSNC’s London headquarters, he says he hopes talks on community pharmacy’s contractual framework will begin in the next couple of months.

Not that “Brexit-related stuff” has impact solely on community pharmacy, Simon asserts. “Equally, the GP contract should’ve been announced months before and they too have been affected by that.”

Despite his insistence that any comparisons between general practice and community pharmacy are wrong, his desire is for the latter to secure a multi-year settlement just as GPs have. Yet three, four, five-year deals in the overworked, underappreciated land of community pharmacy is unchartered territory.

“They are two very separate professions clearly and businesses but the thing I picked up on from the moment I arrived in this job, the absolute core to having a change process in the sector is having a longer than this one-year annual contract,” Simon says.

“The one thing I picked up one and pushed out there was if you can do it for GPs then why can’t you do it for community pharmacy?”

Biggest reforms for 15 years

The biggest reform of GP services for 15 years will be driven by primary care networks (PCNs) which will be powered by over 20,000 staff across England, ranging from pharmacists and physios to social prescribing support workers and paramedics.

The programme will be funded by an extra £4.5 billion which will be invested in community services by 2023 as part of the NHS long-term plan. Given the way NHSE and the chief pharmaceutical officer Keith Ridge have presented the reforms, waxing lyrical about the importance of clinical pharmacists, it appears PCNs are designed to include GP pharmacists not community pharmacists. Simon is asked if this is something he will bring up during his talks.

“Yes and don’t forget, they didn’t say ‘not community pharmacists’ to be fair. Keith Ridge has said he wants to use the skillset of community pharmacy and it’s absolutely vital to the delivery of their vision.

“So I think it would be wrong to say they haven’t mentioned community pharmacy. And in the long-term plan they also mention community pharmacy as well.

“You’re right, there are different phrases used, community pharmacist, clinical pharmacist, GP pharmacist. I’m not a pharmacist, I think that those who have trained in this profession have clear views about what those things are.

“As I’ve said before, I’ve never met a community pharmacist that’s not a clinician. Of course, they are all clinical. They are dealing with patients on a daily basis.

“What we need to focus on is NHS England’s definition of what the type of pharmacist is they want to do the work that they have outlined in the long-term plan. From their definition, that’s what they want to use. The fact they call it a clinical pharmacist is emotive for some people in the profession. I understand that.”

It is put to Simon that some community pharmacists could be forgiven for thinking the reforms generally are geared more towards pharmacists in GP surgeries rather than community pharmacists.

“I think it’s geared towards GPs,” he says matter-of-factly. “I agree with you, clearly NHS England’s vision is of general practice at the centre of this primary care network, integrated with other healthcare professionals including pharmacists.

“What is also clear from the long-term plan and indeed the GP contract is that those clinical pharmacist skills, and for purposes of the tape I’m using quotation marks, those skills and that role can be performed by a pharmacist employed by a GP and can also be performed by a pharmacist employed by a community pharmacy with the skillset that we’ve just talked about. I see this as a big opportunity for community pharmacy as well.”

Long-term plans

Long-term plans and community pharmacy have in the past been uneasy bedfellows. In August 2016 the PSNC and now defunct Pharmacy Voice published the Community Pharmacy Forward View which set out the sector’s ambitions to enhance and expand the personalised care that community pharmacies provide. That vision barely gets a mention now.

When it comes to community pharmacy, the government seems to take a short-term view. Simon is unmoved.

“You’ll have to ask the government as to whether that is the case. I think that the long-term plan and the GP contract both provide with a much clearer idea on how NHS England views community pharmacy and the role of community pharmacy in the future of primary care in this country.

“I think that is positive. It does mean we need to deal with some quite challenging issues as a sector but I think for the first time we’ve got the opportunity, not only to work collaboratively as a sector with the other representative bodies, (and) we have a great relationship with the National Pharmacy Association (NPA), Company Chemists’ Association, Pharmacists’ Defence Association, Royal Pharmaceutical Society, but also working alongside NHS England and the Department of Health in terms of that delivery.

“If you are going to have true collaborative working with your customer, NHS England, then that is the way to do it to ensure delivery on their vision.”

Since governments formed by either of the two big parties have not been in the habit of giving community pharmacy two, three, four, even five-year settlements, what possesses Simon to think this one will? He raises an eyebrow.

“Well, we can only ask can’t we? I think there’s a great precedent there. I’m struggling to think of reasons why we shouldn’t have that.

“If we are as central to the delivery of that vision as has been said and stated in some of the press releases that went out from NHS England, then we can at least ask the question and request a similar length of time, certainly a multi-year settlement, to give us a sense of what the funding envelope looks like for our sector.

“If we are asking contractors, independents and multiples, to make quite significant and serious investment decisions in the future, they need to have some sense of what that envelope looks like.

“If government is genuine about wanting to make the changes they have, then give us a sense of what that envelope looks like.”

The PSNC’s efforts to secure a good, long-term settlement for community pharmacy could be hindered by it’s own legal struggle to halt the government’s swingeing funding cuts.

Late last year during one pharmacy event, Simon said the PSNC had “a bit of a mountain to climb” if it was to gain the government’s trust because ministers regarded community pharmacy as “difficult” and “clearly litigious.”

Damage

He is asked how much damage, superficial or otherwise, judicial reviews by the PSNC and NPA during their highly publicised cuts campaigns might have done to impending contractual negotiations

“It impacted on (the government and NHSE’s) view of the sector and that means, as the negotiator, we have had some relationship-building to do in order to regain an element of trust and for them to accept that we are here to help them as our principle customer, our only customer in some cases, achieve their vision.

“That doesn’t mean we just roll over and accept everything they say. We challenge but we challenge in a supportive way to find the best possible deal for our contractors.”

Simon insists the PSNC’s attempt to repair relationships with ministers and policy-makers is “ongoing.”

Then there is Ridge. The perception that he is not a fan of community pharmacy persists in the wake of his support for hub and spoke dispensing, not to mention his signature at the bottom of that December 17 letter outlining the cuts to community pharmacy funding.

Ridge has not been unaware of criticism that has flown his way, even telling a conference in London last year that he had visited less community pharmacies because he was not sure he would be welcome.

If NHSE officials are taking counsel from Ridge on community pharmacy contractual matters and funding, would that not make the PSNC’s negotiations even harder?

“You’ll have to ask Keith as to what his view of community pharmacy is. It’s not for me to say what that is. I have found him nothing other than professional and helpful in the discussions that we have had,” Simon says diplomatically.

“He’s the chief pharmaceutical officer for England and it is inconceivable that PSNC in particular, as the national negotiator for all community pharmacy, that we do not have a relationship with the chief pharmaceutical officer for England.

“Just as he has been professional with me and PSNC, we will always be professional with him.”

As we talk about what may or may not be happening behind the scenes at NHSE, it becomes increasingly apparent how controlled and calm Simon is. Pretty good qualities, you might think, to take into tense contract negotiations.

One thing did concern him however. “Paragraph 4.21 if I’m not mistaken,” he says, retaining his composure.

Embedded within the NHS long-term plan was the paragraph: “In community pharmacy, we will work with government to make greater use of community pharmacists’ skills and opportunities to engage patients, while also exploring further efficiencies through reform of reimbursement and wider supply arrangements.”

Cynics and fearmongers would say that points to more cuts. Simon suggests it was “vague.”

“It is a vaguely-worded sentence. I’d like to think it is vaguely-worded in order to allow us to work with NHS England about what it actually means.

“Clearly, we need to have a discussion with NHS England and Department of Health about funding, remuneration, especially as we move to a more, perhaps, services-led offering and when it comes to efficiencies, their word not mine, we know the secretary of state has made a number of statements about the use of technology in healthcare.

“I would suggest it is wrapped up with that. It may also be wrapped up with the fact that NHS England have still got to make year-on-year savings for the next five years and no doubt they will be looking to the entirety of healthcare to help them do that.”

But wasn’t the vagueness of that passage reason for concern? Simon offers a smile.

“You’ll get the feeling here that I’m quite positive. I’m very positive and optimistic about the sector. Vagueness works both ways doesn’t it.

“As a negotiator, I’d say that’s great because it allows us the opportunity to influence the outcome. If it’s absolutely nailed down, then it’s tricky.

“There, there’s no wriggle-room. There, there’s wriggle-room and we need to use that.”

Uncertainty

Despite ambiguously-worded policy documents, ministerial hesitance to talk pharmacy funding and uncertainty about what is going on behind the scenes in the heart of healthcare policymaking institutions, community pharmacists’ destinies are in their hands.

More specifically, pharmacists’ destinies are largely in the hands of local pharmaceutical committees (LPCs) who are tasked with driving forward the community pharmacy agenda locally.

“I think they’ve got a hard job because there’s no particular set template, if that’s the right word,” Simon says.

“They vary in size, they vary in demographic, they vary in terms of the relationships they have with their commissioners, with general practice, and I think therefore it is wrong to say they should all look like this particular LPC.

“The important thing is about whether they provide value and whether they provide a good service for their contractors, the ones they are serving. I see it as one of PSNC’s top aims and objectives for 2019 to ensure we are providing LPCs with the support, guidance and information they need to do just that.”

He reveals he has visited about half of the 70 LPCs in England and “been impressed with the way they are focused on their contractors and channel the issues of their contractors to make sure the PSNC has got the data it needs to encourage them to let us know when they are having issues with concession prices.”

He adds: “I think we’ll be looking at trying to gather a little bit more data about LPCs over the course of the year to help them help themselves.”

Yet still the Department of Health and Social Care continues to announce concessionary prices towards the end of each month, making it extremely difficult for contractors to plan their business.

“We are looking, with the Department of Health, and technology will help us here, on how we can create a more responsive concessions process.

“It is enormously time-consuming work, not helped by the fact we have the number of concession lines we do. In order to collate the data from contractors and from other sources, in order to get that together, get it over to the Department of Health who in turn have to look at their own data collection, wholesalers and from other sources, to then come up with a figure, concessionary price, which we then negotiate to try and get often better, that takes time. You can’t do that quickly.

“You talk about the effectiveness of LPCs. It’s quite right that people should ask about the effectiveness of PSNC. Looking back over the figures for the last year, we have prevented over £330 million concessionary loss for contractors.

“That is a huge figure, not even taking into consideration many tens of millions of pounds we provide effectively in advice and guidance and regulatory work.

“This is an organisation (that has) a very, very small office in Enfield (the PSNC’s pricing audit centre) on an annual income of £3million. So for every pound in levy, we provide over £130, £150 of value. That is, I think, a really return on investment for contractors. What, £250 a contractor?”

One wonders if the PSNC has asked LPCs for an increase in their levy so the negotiator can improve its support.

“I wrote to all LPCs late last year to thanks them for all their time and effort in briefing me in my first year. I said I thought we provided an excellent service, as did many of the LPCs who wrote back in response.

“I did say if more is needed from us, we can’t do it on the current budget but it would be wrong for us to just assume that’s the case and therefore we’ll be talking to LPCs this year to see if they do want more from us.

“But for the third, fourth, fifth year running, we have not increased our levy. For 2019-2020 the levy will be flat again.”