General Comments

The EPB endorses the Government’s aim to support those personnel providing healthcare directly to patients and the public. In particular we support the principle of ‘no decision about me without me’. Whilst we support the restoration of faith in the front line practitioners emphasised in this consultation and agree that those who are closest to patients are best placed to make decisions for their care, we are concerned with the capacity of GP consortia to undertake these new roles. Changes to the delivery of patient care will be essential for the realisation of the governments agenda, such change should be brought about through effective engagement with all relevant professionals and providers to bring about real benefits to patients.

We would like to take this opportunity to emphasise the valuable role that pharmacists play in the delivery of care to patients and to demonstrate the outcomes they can and do deliver.

Pharmacists are the experts in the use and optimisation of medicines. The prescribing and supply of medicines is by far the most frequent intervention made within the NHS. The expenditure on medicines dispensed through community pharmacy continues to increase with the total spend in 2009 of over £8.5 billion [1]. The cost of medicines is the greatest area of expenditure, following staff costs, within the NHS. Pharmacists can not only make significant savings to the prescribing budget but can also help ensure that patients understand and take their medicines in an appropriate manner. This will reduce the amount of medicines wasted as well as the number of unplanned admissions to secondary care caused by patients not taking their medicines correctly. Pharmacists have ensured the quality, safety and efficacy of medicines within the NHS for many years and this should be a central aspect of the Quality, Innovation, Productivity and Prevention (QIPP) agenda. The recent Bow Group report ‘Delivering Enhanced Services in a Modern NHS: improving Outcomes in Public Health and Long Term Conditions’ concludes that “enhanced pharmacy services are an under-utilised resource that can deliver innovative, cost-effective services to patients in a highly accessible manner, whilst facilitating the NHS to achieve its QIPP objectives”.

Community pharmacies often see members of the public that do not access healthcare through any other means, these people are often those that are most vulnerable in the community e.g. refugees, asylum seekers, students and drug misusers. Many pharmacies have developed bespoke services for such groups of people and it is unclear how the continuation of such services will be ensured in the future as they fall between the responsibilities of the NHS and public health. An estimated 1.6 million people visit a community pharmacy each day, of which 1.2 million do so for health reasons. [2]

All pharmacists currently working in Primary Care Trusts (PCTs) will be affected by the changes proposed in this consultation. The unique skills of these pharmacists must not be lost when PCTs no longer exist. The services that these pharmacists provide are essential for patient care and the containing of NHS resources. Some of the key areas are the management of the prescribing budget and development of prescribing incentive schemes, the procurement of community pharmacy services, the development of Pharmaceutical Needs Assessment (PNA) and pharmacy input into the wider commissioning of health services, including public health, across the PCT. We believe that primary care pharmacists must continue to play an active role in the clinical design of local services and patient pathways. The vital role of medicines management to ensure quality and transparency in all commissioning decisions about medicines must be encouraged to continue and develop through local decision making processes. Many of these pharmacists have taken on the role of Accountable Officer (AO) for their organisation. This role ensures the safe management of controlled drugs and ensures patient safety where these particular medicines are concerned. It is not clear how the role of AO will fit into the new NHS Structure and at what level it will sit, it is possible that this role could be undertaken across a number of consortia. As GP consortia take more responsibility they will require this unique set of skills, to be effective, for the public they serve.

Specialist pharmacy services are in general, commissioned across large geographical areas and several different organisations. We are concerned that they won’t be continued purely because of the measures contained in these white papers which promote localised commissioning. Pharmacy specialist services include the delivery of medicines information, pharmaceutical quality assurance and medicines usage and safety are currently commissioned across Strategic Health Authorities (SHAs). These services deliver expert advice and high-level support for the commissioning, provision and assurance of complex or novel medicines-related services for NHS patients. There is experience of commissioning specialist pharmacy services through a specialised commissioning mechanism for 4 out of the 10 SHAs in England. A scoping exercise is underway to identify the commissioning, funding and delivery arrangements for specialist pharmacy services across England. The NHS Commissioning Board (NHSCB) potentially offers a mechanism to commission specialist pharmacy services to a consistent definition and in a coherent manner across England. Commissioning at a national level will reduce the problem of variability and will ensure that quality standards are applied equally across the NHS. Pharmacists also play a vital role in the procurement of medicines and this must not be forgotten as the proposed new structures develop. The EPB would welcome the opportunity to work with the Department of Health to address these concerns and develop solutions.

As the NHS moves towards the commissioning models proposed in this consultation it is important to ensure that all relevant healthcare professionals have input into the development of quality standards (by NICE) and the model contracts and service specifications which will be developed by the NHSCB. In redesigning the architecture of the NHS it will be crucial to involve patients and the public far more meaningfully than has been the case in the past. We suggest that there are real benefits for patients and the NHS in following integrated models of care – with healthcare professionals delivering relevant sections of care along the patient pathway which they are the most appropriate professional to deliver. For the NHS to truly deliver benefits to patients there needs to be inter-professional collaboration rather than a focus on competition.

Community pharmacists currently provide a range of services that must continue to be commissioned in the future:

• Prescription interventions which enhance patient safety.
• Referring to other healthcare practitioners and signposting patients to voluntary organisations.
• Provision of advice to enable self care.
• Medicines Use Reviews. A total of 1,397,319 Medicines Use Reviews (MUR) were conducted by community pharmacy contractors in England in 2008-09 [3] . These MURs support medicines adherence, thereby potentially reducing unplanned admissions. Between 4% and 5% of hospital admissions are due to medicines-related problems which are preventable and between 11% and 30% of these admissions result from patients not using their medicines as recommended by the prescriber [4]. Avoiding such hospital admissions can save vast amounts of money as well as improving patient care .
• Minor ailment services. Treating minor ailments in a community pharmacy setting rather than in general practice can save money and allow the GP to concentrate on more serious conditions. The average GP surgery consultation lasts 11.7 minutes and costs £32. The same 11.7 minute consultation in pharmacy would cost £18 and deliver an equally, or even more effective outcome [5].
• Helping patients manage long-term conditions. Between one third and a half of all medicines prescribed for long term conditions are thought not to be taken as recommended [6]. Pharmacists have a clear role in supporting patient with long term conditions and we encourage the development of the ‘first prescription service’ as outlined in ‘Pharmacy In England: Building on strengths, delivering the future’ (2008).
• Pharmacist consultations. Research carried out by PriceWaterhouseCoopers and the association of Finnish Pharmacies suggests that pharmacy expertise reduced the need for prescriptions by 2.6 million over a year. By routinely using pharmacists for consultations, rather than going directly to the doctor, GP visits were reduced by 6.2 million and there were three quarter of a million less trips to accident and emergency and 123,000 less nights in hospitals. Overall this saved around £450 million [7].
• The promotion of Public health. There is large amount of evidence that supports pharmacists’ role in the prevention of ill health and health promotion. For example, community pharmacy-based stop smoking services run by trained pharmacy staff are cost effective. Quit rates achieved by one-to-one smoking cessation services provided by community pharmacists and primary care nurses are similar and although quit rates are lower for one-to-one advice than group interventions with specialist behavioural support, pharmacy is able to cater for large numbers at a time and in locations that are acceptable to patients. [8]  In Scotland, in 2009, 56% of quit attempts were made through community pharmacy delivered services, although in some areas this was as high as 83% [9].

We have a number of specific concerns about the proposed new NHS structure:

1. We understand that the Pharmaceutical Needs Assessment (PNA) is to be used as a tool to manage the control of entry for new pharmaceutical services in a geographical area. We are also aware that the PNA is likely to form part of the Joint Strategic Needs Assessment (JSNA), delivered by local authorities (LAs) and we would support this. The Government’s proposals point to the contract for essential services being managed by the NHSCB. We are unclear on how this arrangement will work unless LAs are able to determine the future pharmaceutical requirements of the communities they serve. We wish to work with the Government and other pharmacy bodies to resolve this matter.
2. It is not clear how the provision of enhanced pharmaceutical services fit within these new structures as it appears that community pharmacy could have several pay masters; - the NHSCB in relation to the national contract, GP consortia for the delivery of local services and Local authorities for the delivery of public health services. We are concerned as to how all these partners will work together to ensure appropriate service delivery from pharmacy as different elements of a holistic service may be commissioned by different organisations This could lead to a fragmentation of service provision for patients.
3. The consultation does not cover out of hours services. These should be considered as integral to the commissioning framework. Tightening up the links between pharmacy and out of hours providers would hugely benefit patient care and patient safety. The use of pharmacies providing extended opening hours offers an opportunity to increase access to NHS services.
4. The EPB has concerns over the future of commissioning for pharmacy-led specialist services. These services cover different geographical areas and we believe there is a need to have arrangements for these specialist services at a regional level (not necessarily as small as GP consortia level). This will ensure that patient pathways for these more complex conditions are developed and used appropriately. The different professionals and managers will need to come together to ensure that this happens.  The existing clinical networks must not be lost as the new structures develop. This could be managed through GP consortia coming together to commission specialist services. While this may work it would be reliant upon an organisation of GP consortia which has not been clearly envisaged in the white paper.
5. There is no mention of the local formal representative bodies for any of the healthcare professions i.e. the local pharmaceutical committee. We assume their role will continue, although they will be working with different partners in the future. We would support the continuation of such bodies at a local level.
6. We propose that the boards of GP consortia should have input from an appropriate range of healthcare professionals as full members.
7. Additionally, we suggest that the NHSCB should receive expert advice from all patient-facing healthcare practitioners, including pharmacists, so that the benefits of innovation, best practice and cost efficiencies can be maximised. Such a multidisciplinary approach will lead to fully integrated care pathways. We would propose that NHSCB creates links between National Clinical Directors (Tzars) and utilise their skills and knowledge to help develop the new NHS. Pharmaceutical advice will be crucial at this level to ensure successful budgetary management within the QIPP agenda. The pharmacy profession has much to offer the new NHS and should feed in to the formation and development of key strategic decisions around quality standards, service models and pricing to ensure that their roles are recognised and supported for the benefit of patients and the public
8. We are particularly concerned about the lack of scrutiny built in to the new systems for commissioning local services. The EPB feels there must be clearer division between commissioners and providers. It will be crucial to ensure that that all GP commissioners have the required expertise and patient-centred multidisciplinary input to commission effectively

The EPB wishes to see more detail on how the proposed ‘any willing provider’ model will work in conjunction with the commissioning of specific services by GP consortia. We would particularly like to understand the governance underpinning the decision-making process on which services will use which commissioning process. The process of creating the JSNA and commissioning of services must not be disjointed. LAs will lead on the creation of the JSNA, and GP consortia will commission. It is not apparent how GP consortia will commission according to the outcomes of the JSNA.

Under PCTs, community pharmacists experienced mixed results in the commissioning of services from pharmacy. The Isle of Wight commissioned up to 15 different services, whereas other PCTs commissioned very few, with no reasoning behind the difference. We would hope that the new structural arrangements would not lead to such variability and that all providers were treated in the same way. If there is wide variability then this should be fully justifiable in terms of patient benefits and outcomes.

The EPB believes that public health services, with clear benefits to patients, such as smoking cessation and sexual health should be commissioned at a national level to avoid a similar situation developing under these new proposals. Our concerns are highlighted in more detail in the answers to the questions below.

We propose that all healthcare providers should have equal access to training and education. We further propose that all practitioners should receive funding to cover the costs of locum support whilst training is undertaken, as currently occurs with GPs. Page 14, section 3.8 states that one of the roles of GP consortia is to ‘provide oversight, with the NHS Commissioning Board, of healthcare provider’s training and education plans’. This should be defined more explicitly. There must be appropriate oversight and governance to ensure that GP consortia have the knowledge, skills and capability to carry out this role on behalf of all potential providers.

We are working with the other national pharmacy organisations to present the evidence base for the provision of pharmaceutical services and pharmacist’s role in public health. Pharmacy can, and has, demonstrated its benefits to patients and the public. We accept that more work needs to be done in establishing measures of quality for pharmacy e.g. quality metrics.

 

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Specific questions  

1. In what practical ways can the NHS Commissioning Board most effectively engage GP consortia in influencing the commissioning of national and regional specialised services and the commissioning of maternity services?

The GP consortia need to work with other organisations and seek the advice of other healthcare professionals involved in patient pathways. We have particular concerns that services provided by Specialist Pharmacy Services will be lost. These services include the provision of medicines information (which has a role in providing advice to NHS Direct and out of hours services), medicines assurance and medicines use and safety. These functions need to be commissioned at a national level to ensure effective data collection, standardisation and dissemination across the NHS. This will enable independent quality assurance and a drive to quality improvement. Specialist pharmacy services provide support to providers and commissioners in addition to patients. To date, they have enabled the development of strong infrastructures, sharing of good practice and robust contact databases.

2. How can the NHS Commissioning Board and GP consortia best work together to ensure effective commissioning of low volume services?

Low volume services are most likely to involve services from specialist practitioners. These practitioners must be included in the process to ensure efficient commissioning of services that fully meet patient requirements.  

3. Are there any services currently commissioned as regional specialised services that could potentially be commissioned in the future by GP consortia?

The RPS believes that regionalised specialised services have proved to be effective and efficient. Any change to this system is likely to result in a diminution of care standards for patients. The RPS does not agree to any change in the process of regionally commissioned specialised services.

4. How can other primary care contractors most effectively be involved in commissioning services to which they refer patients, e.g. the role of primary care dentists in commissioning hospital and specialist dental services and the role of primary ophthalmic providers in commissioning hospital eye services?

Pharmacists do not currently officially refer to other services, although they do often refer patients to general practice, other services or recommend self treatment. We would like to see pharmacists provided with the ability to refer directly to secondary care for specifically defined pathways. The ultimate aim would be to reduce the length of patients’ pathways and reduce costs by freeing up GP time.

We would like to see the evolution of integrated care pathways that offer the most cost-effective as well as the best quality outcomes for patients. This will require all healthcare professionals to work together in the development of these pathways with jointly agreed referral mechanisms in place. The use of medicines is a component of almost all disease pathways, and we believe pharmacists should have an involvement in the creation of all relevant pathways.

The transfer of patients between primary, secondary, tertiary etc care, introduces unnecessary patient risk. Pharmacy is the ‘missing link’ between these care settings and we would support the development of services that include referral on discharge to a community pharmacist for a medicines use review (MUR). The development of a ‘first prescription service’ would also support patients more fully and help them to understand their medicines and their condition or disease.

5. How can GP consortia most effectively take responsibility for improving the quality of the primary care provided by their constituent practices?

We have no comments on this question

6. What arrangements will support the most effective relationship between the NHS Commissioning Board and GP consortia in relation to monitoring and managing primary care performance?

We believe that a key element of this relationship will be for both organisations to have a clear understanding of what is acceptable performance from care providers. There need to be clear, nationally agreed standards, produced by NICE in conjunction with representative professional bodies, and templates for service contracts. Medicines are the most common intervention made within the NHS so these need to be included in the performance management systems as a national standard.

We would strongly suggest that there is a named pharmacist within each GP consortia with responsibility for the arrangements of governance of medicines.

7. What safeguards are likely to be most effective in ensuring transparency and fairness in commissioning services from primary care and in promoting patient choice?

All willing providers need to have the same access to data and the same level of support to provide services. We would support the use of the ‘any willing provider’ the must be a level playing field for all providers, with equal opportunities for all.  An example of this is the length of contract, which needs to be long enough for private sector operators to recoup the levels of investment required to deliver a high-quality, high standard service.

Public funding is used to support public sector providers – funding for: IT, other equipment and staff, training. This funding must be taken into consideration during the commissioning process.

Fair access to enabling technology for all providers would ensure more consistent care and improve patient safety, for these reasons we support the ongoing work on access to the Summary Care Records for healthcare professionals.

World Class Commissioning includes a measure on the number and type of services commissioned from community pharmacy; we suggest this measure is carried forward in the assessment of GP consortia to ensure equity and transparency of the commissioning process.

The RPS considers it essential for all healthcare professionals have ‘protected time’ for education and training – funding to cover locum costs whilst healthcare practitioners undergo continuing professional development or compulsory training.

We believe that there must be a quick and responsive commissioning appeal process in place which is accessible to all potential providers.

8. How can the NHS Commissioning Board develop effective relationships with GP consortia, so that the national framework of quality standards, model contracts, tariffs, and commissioning networks best supports local commissioning?

The NHS CB needs to ensure the widest possible buy-in to the development of the Quality Standards, model contracts, tariffs etc from the outset. This means wide engagement and real involvement in their development for all health and social care professions.

9. Are there other activities that could be undertaken by the NHS Commissioning Board to support efficient and effective local commissioning?

We would see an additional role for NHS CB being to develop model care pathways i.e. integrated care pathways. There are a number of examples of these pathways already available such as ‘map of medicines’ and those used as part of the 18 week pathway programme. The NHS CB also should have a responsibility to check that all willing providers are given an equal opportunity.

There needs to be robust performance review that is applicable to everyone and current performance needs to be taken into account when contracts are renewed.

10. What features should be considered essential for the governance of GP consortia?

There should be recognition and input at GP consortia board level from lay people and other professionals i.e. non-executive directors. In order to reassure all potential providers there needs to be a robust provider / commissioner split with genuine accountability.

GP consortia must publish annual reports and as many meeting as possible should be held in public.

11. How far should GP consortia have flexibility to include some practices that are not part of a geographically discrete area?

We have no comments on this question

12. Should there be a minimum and/or maximum population size for GP consortia?

We have no comments on this question

13. How can GP consortia best be supported in developing their own capacity and capability in commissioning?

It is unlikely that that all GP consortia will have the capacity and capability to commission effectively in the first instance. In order to make their commissioning more effective they will require a wide range of expertise and skills available within their commissioning functions. GP consortia need to consult with every relevant stakeholder on how commissioning can be undertaken. Ultimately, we would like to see a range of healthcare professionals, including pharmacy having a seat on every Consortium Board. Additionally, we believe that patient representation and engagement an essential part of effective commissioning.

14. What support will GP consortia need to access and evaluate external providers of commissioning support?

We have no comments on this question

15. Are these the right criteria for an effective system of financial risk management? What support will GP consortia need to help them manage risk?

Pharmacists are likely to be employees or have contracts with GP consortia. There must be processes in place that ensure such pharmacists are not left at financial risk if a GP consortium fails. Also, there needs to be assurances around service continuity from a patient’s perspective. The NHS CB should have oversight and responsibility around this

16. What safeguards are likely to be most effective in demonstrating transparency and fairness in investment decisions and in promoting choice and competition?

We have no comments on this question except for what has been said in previous answers, especially our response to question 7.

17.  What are the key elements that you would expect to see reflected in a commissioning outcomes framework?

• Patient outcomes including patient experience (PROMs)
• Decrease in unplanned admissions to hospital
• Decrease in health inequalities
• Effectiveness (clinical and cost) – value for money

Learning should be distilled from the process of World Class Commissioning and this should be linked to the NHS outcomes framework.

18. Should some part of GP practice income be linked to the outcomes that the practice achieves as part of its wider commissioning consortium?

We have no comments on this question

19. What arrangements will best ensure that GP consortia operate in ways that are consistent with promoting equality and reducing avoidable inequalities in health?

The services that GP consortia commission must be linked to the outcomes of the specific Joint Strategic Needs assessment covering that consortium’s area. The RPS expects JSNAs to identify the reduction of health inequalities as a priority health issue.

Performance against JSNAs should be part of the remit of every Health and Wellbeing Committee.

The RPS anticipates GP consortia and individual providers being measured against the JSNA for standards of patient outcomes and levels of health improvement. 

20. How can GP consortia and the NHS Commissioning Board best involve patients in making commissioning decisions that are built on patient insight?

Pharmacists and their staff have good relationships with their patients and the public. The community pharmacy setting could be used more effectively to harness the views of the patients and the public as well as to provide relevant information to them

21. How can GP consortia best work alongside community partners (including seldom heard groups) to ensure that commissioning decisions are equitable, and reflect public voice and local priorities?

Please see answer to question 20 above

22. How can we build on and strengthen existing systems of engagement such as Local HealthWatch and GP practices’ Patient Participation Groups?

Pharmacy is the shop window of the NHS in any locality and they have ready access to patients and the public. Pharmacies could be a hub of information – not only provision to patients but also as recipients of information from patients and the public, also people not currently on any GP practice list. Pharmacy understands its customers and its market i.e. they have unique retail competencies which could assist GP consortia in the commissioning of services.

23. What action needs to be taken to ensure that no-one is disadvantaged by the proposals, and how do you think they can promote equality of opportunity and outcome for all patients and, where appropriate, staff?

There must be a requirement for GP consortia to deliver against the relevant JSNA. We believe that a reduction in health inequalities must be a priority for GP consortia and the NHS as a whole.  There must be robust and meaningful input from patients and other health and social care professionals (other than GPs) in the development of NHS systems and processes.

The RPS believes that absolute fairness is impossible to achieve in a system where funds and services will be limited. We are unconvinced that the proposed changes will result in removing disadvantage for all groups. In fact, it will encourage a postcode lottery purely because decisions are being handed down from 152 PCTs to approximately 500 GP consortia.

24. How can GP practices begin to make stronger links with local authorities and identify how best to prepare to work together on the issues identified above?

GP consortia and local authority boundaries are unlikely to be co-terminus. This will result in patients and the public within the same local authority area receiving different standards of healthcare – possibly even different services. There must be an element of communication between neighbouring consortia to try and minimise such differences.

The role of Health and Wellbeing Boards should be to bring local authorities and GP consortia together to identify gaps in service provision in the JSNA and prioritise which services need to be delivered. The RPS envisages JSNA as the key to making this new structure work at a local level. There needs to be a strong relationship between Directors of public health and GP consortia and also between GP practices and other healthcare professionals to help facilitate dialogue between other healthcare providers and minimise variation between commissioners in the same consortium area.

25. Where can we learn from current best practice in relation to joint working and partnership, for instance in relation to Care Trusts, Children’s Trusts and pooled budgets? What aspects of current practice will need to be preserved in the transition to the new arrangements?

26. How can multi-professional involvement in commissioning most effectively be promoted and sustained?

We would recommend that other healthcare professionals are included on the GP consortia Board and we would want such a seat for pharmacy.

All providers should have equitable access to training and education and protected time in which to undertake this. There should also be protected time set aside to enable the involvement of all clinicians to in the development of integrated care pathways.

We wish to see the promotion of a joint leadership programme across all professions involved in healthcare provision.

We are concerned that a big transitional gap may emerge during the transfer of roles, responsibilities and commissioning processes which could jeopardise the health of the public.

Further information

For further information or any queries you may have on our consultation response please contact Heidi Wright at  or 0207 572 2602.

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References

1. Data taken from NHS Information Centre
2. Improving Quality in Primary care, Department of Health 2009
3. (NHS Information Centre, General Pharmaceutical services in England, 2009)
4. NICE, National Costing Statement: Medicines Adherence, 2009
5. Bow Group, September 2010, Delivering Enhanced Pharmacy Services in a Modern NHS
6. Bow Group, September 2010, Delivering Enhanced Pharmacy Services in a Modern NHS
7. Pharmacy Professional: October 2010. Lessons from Scandinavia and a drug dispensing machine.
8. Healthy Living Pharmacy Project, a literature review. December 2009
9. NHS Smoking Cessation service Statistics (Scotland) 2009

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