General comments

The EPB understands the current need to provide a more effective service to patients and also the need to do so within the current economic constraints. As medicines are an increasingly important part of treating patient’s ill health, we feel that the role of pharmacists, as the experts in drug treatment, will be central to both the quality of outcomes and gaining the best value from the NHS drugs bill.

We believe that pharmacists will be seen as central to the delivery of public health as it evolves within the new NHS and Public Health Service. Pharmacies are sited in accessible locations and are open at times convenient to the public. Pharmacists often advise members of the public who do not access other NHS services. Therefore, they have a fundamental role in the delivery of health improvement services and a key role in the reduction of health inequalities.

The public are also being asked to take more responsibility for their own health. Pharmacists can and do play a major role in self–care, assisting patients to care for themselves.

Community pharmacy also has a unique role in that it is one of the three essential businesses that ensure the economic prosperity in a community, the other two being a GP surgery and a source of cash (usually a post office) [1]. If any of these is absent, it jeopardises the business community. Community pharmacies are local premises that can provide employment for local residents and a pathway into new skills and training opportunities. They can also provide accessible information to the public on community initiatives such as ‘warm front’ whereby elderly and vulnerable patients can claim grants to help with their heating bills.

Liberating the NHS »

Putting patients and the public first »

Improving healthcare outcomes »

Autonomy, accountability and democratic legitimacy »

Cutting bureaucracy and improving efficiency »

Conclusion: making it happen »

1. Liberating the NHS

1.1-1.28

An NHS that offers real choice and informs patients in order for them to make appropriate decisions about their treatments is a good aspiration.

The EPB envisages a National Health Service that has the GP at the centre of diagnosis and delivery of services to patients with the most complex or multiple conditions. The EPB believes that pharmacists should be central in all aspects of patient care that involve medicines. Most Long Term Conditions (LTCs) are now treated with medicines. The EPB wants to move towards a care model where GPs refer patients directly to pharmacists who will manage the majority of patients with long term conditions.

The EPB also envisages other healthcare providers serving as part of an integrated healthcare team that fully utilises the specialised skills of the other professionals. This mix of skills will offer a cost-effective and efficient model that displays a co-ordinated approach to healthcare where choices of treatments are offered from a range of providers. It is likely that GPs will be responsible for determining the exact mix of skills required to support every individual case that is presented to them. To do this effectively they will require the support of other clinicians. This envisions a mixed economy of providers where patient care is always the first consideration.

The key test for every pathway of care agreed between a patient and GP must be whether a more effective course of care is available from any other provider. This test must be at the heart of any governance arrangements put into place to monitor the effectiveness of GP consortia.

 

2. Putting patients and the public first

2.1-2.3

The EPB fully supports the ideal of fully-informed patients jointly deciding with clinicians on a suitable pathway of care that most fits their individual needs. Further, the EPB believes that patients require a fully independent form of advice when deciding upon the most suitable form of care for them. Whilst it is anticipated that a majority of patients will be able to decide upon a course of treatment that best suits their needs, a proportion of patients may be unable do this. Therefore there should be mechanisms in place to support patients unable to make such decisions independently, a potential role for Local HealthWatch.

2.4

The EPB notes the introduction of the NHS Commissioning Board’s (NHSCB) role to champion patient and carer involvement. We would like to see the NHSCB having expert advice from clinicians from all patient facing professions, including pharmacists, so that ongoing improvements in patient involvement will be embraced by providers. Such a multidisciplinary approach will lead to robust integrated care pathways.

2.5-2.10

The information revolution will be welcomed by pharmacists, who have for years been at the forefront of informing patients and embedding IT into their practice. 

We fully support the government’s moves to provide accurate, relevant and informative data for patients to help inform them about their choices of care. We also support the need for patients to be able to communicate with all healthcare professionals providing their care.

The measurable patient outcomes on which all practitioners will be assessed must be determined by an independent body, such as HealthWatch, to ensure consistency of approach across all healthcare providers. Patient reported outcome measures (PROMs) and patient experience surveys (already part of community pharmacy essential services) may well provide valuable feedback to providers, commissioners and regulators.

The white paper speaks of an information revolution; however the detail is limited to the provision of patient information. It does not acknowledge the importance of providing consistent professional, authoritative and independent information and advice on (for example) drugs and medicine in support of prescribing and frontline services. The EPB would welcome this revolutionary approach being applied to the decision support tools used by clinicians. The recent level of investment in NHS IT has not delivered an adequate, standards-based and interoperable IT and information platform.

2.11-2.12

All relevant healthcare professionals should have appropriate access to patient records to inform their discussions with patients and to update the record with decisions made that affect subsequent treatments by other practitioners. Without more widespread access the expansion of “any willing provider” will be limited. The use of electronic Summary Care Records with appropriate levels of access will be a key enabler of the reforms envisaged in the white paper. To facilitate this, software suppliers should be encouraged to consider development of integrated primary care systems rather than systems for GPs, pharmacists or commissioners in isolation.

2.14

It is important that there should be no barriers to patients requiring information on healthcare providers or outcomes from different care pathways. It will however only benefit patients if the information provided is in a consistent format across all providers.

2.15-2.21

The Government rightly identifies patient choice as a key element to service provision within the NHS. However, it fails to mention any consideration of utilising the strengths within a multidisciplinary group of healthcare practitioners to work together on a specific care pathway, providing patients with the relevant expertise at every stage of their care. Such a model of integrated service provision offers real cost benefits in using the relevant professional only at times when they are the most suitable for the task.

The proposed exploration of patient choice will need to consider how GPs conduct consultations with patients to describe and promote a multiplicity of provision. The ability of patients to exercise choice is tied to the introduction of “any willing provider” so that the patient’s freedom is enabled by multiple providers from which to select. Pharmacists working in the community are keen to provide more services to their patients but have been less successful then originally envisaged under the current PCT or practice based commissioning models. They welcome the opportunity for real collaborative working and the ability to provide NHS services to patients at accessible locations at times convenient to patients. We therefore envisage pharmacists being a key provider of GP consortia commissioned services.

2.26

The EPB believes that standards of service provision will be raised with the introduction of an enhanced patient voice. There must, however, be a clear understanding of what should be expected from healthcare practitioners, and what is unrealistic. In the interests of balance, healthcare practitioners must also have a right of reply to any points raised by patients and the public.

 

3. Improving healthcare outcomes

3.1-3.4

We are pleased to see that the new Government is happy to continue the work of Lord Darzi, focusing on quality outcomes and general quality improvement to enhance patient safety. We welcome the approach outlined where relationships between professionals and patients are strengthened and supported.

It is right that patients are asked to measure outcomes and that standards of services are monitored. This information must be used in conjunction with clinical outcomes when these services need to be re-commissioned so that previous standards of care can be taken into account.

It is important that the measures used are consistent across all professions involved in providing services in a way that does not favour one provider over another. We support the assertion that healthcare outcomes “improve most rapidly when clinicians are engaged, and creativity, research participation and professionalism are allowed to flourish”. However, many pharmacy clinicians do not participate in research due to a lack of protected time for such activity within their clinical role. Healthcare outcomes would therefore benefit from the allocation of funding for pharmacists to undertake training to increase clinical research, like that available to their colleagues in the healthcare team.

3.5-3.7

Outcome based performance should be effective in setting the direction for the NHS, public health and social care. In setting national objectives for the public health service and national outcome goals for the NHSCB the Secretary of State should ensure that these are framed in a way that provides the maximum opportunity for collaboration across these organisations. The two must be clearly distinct and supported by principles or criteria that show what should be delivered by which organisation locally, but also highlight the benefits to patients and to cost savings from collaboration. We encourage a system where all healthcare professionals work collaboratively rather than in competition, for the benefit of patients.

3.10-3.15

The EPB expects that clinician input into developing both a set of indicators for the Outcomes Framework and the new NICE standards will include all health professions. We would like to see every Royal College and Professional Body involved in the development of quality standards. Such involvement will enhance the ownership of standards across NHS providers.

3.16

The Government’s commitment that research remains a core function of the NHS is welcomed by the RPS, as research remains fundamental to ensuring improvements and advances in the delivery and quality of care.

The EPB interprets the Government’s commitment to research as an indication that existing public funding for health research will, at the least, be sustained at current levels.

The EPB believes that patients and the public receive safe, high quality treatments and interventions when these are based on robust evidence. However, given that “best evidence” may not always be available, the EPB would expect a measure of lateral thinking to be applied when making changes to healthcare;  generalising findings from one context to another, e.g. from one disease state to another, to support rapid mobilisation of knowledge for the benefit of patients.

The EPB supports the aspiration to “unlock synergies” between research, education and patient care, with patients as equal partners in research (from design to dissemination), given the cited benefits of improvements in patient outcomes and cost effectiveness.

Continued and varied opportunities for healthcare professionals to partner with patients and academics to analyse, evaluate and research existing and new treatments and interventions is a primary concern for the EPB. We are encouraged by the Government’s commitment to the promotion of existing National Institute for Health Research (NIHR) infrastructure to support the conduct and translation of research into practice. However, the EPB believes that existing clinical funding available to individual healthcare professions requires review, as pharmacy professionals currently have fewer opportunities within the NIHR funding streams than their colleagues in medicine, dentistry, nursing, midwifery and allied health professions.

3.17

Successful commissioning needs to take outcomes, cost and availability into account when deciding upon which service should be commissioned. A co-ordinated scrutiny process needs to take all three aspects into account to monitor and measure commissioning effectiveness. It will be very difficult to measure outcomes and cost when they are monitored by different bodies. This will need to be underpinned by the free and transparent flow of information and we would see this as a clear role for the Health and Social Care Information Centre.

3.22

Pharmacists have a vital role in optimising medicines use and supporting patient adherence which both reduce costs to the NHS and enhance patient outcomes. The EPB agrees with the Governments view that pharmacists have a role in achieving “better value in the use of medicines”. This role should be carried out through enhancement of the community pharmacy contract and this builds upon the current work of pharmacists in secondary care who have been improving the value achieved by the NHS from medicines for many years. As well as gaining better value from the use of medicines the NHS should utilise pharmacists to maximise patient outcomes from medicines. The expenditure on medicines dispensed through community pharmacy continues to increase with the total in 2009 of over £8.5 billion [1]. Behind staff costs, expenditure on medicines is the highest cost to the NHS. It is well known that around 30 - 50% of medicines are not taken as the prescriber intended. [2] Pharmacists can have a beneficial impact in this high cost area for the NHS. They have the skills and expertise to maximise the benefits of medicines and minimise the risks thereby improving efficiency of patient care.

The role of pharmacists in optimising the use of medicines is one which they are uniquely equipped to carry out. The management of patients with LTCs through medication should be the part of the care pathway that is the responsibility of pharmacists, as the most suitable clinician with expertise in drug therapy.

Each patient care pathway should be examined in the light of the QIPP agenda. As the pathway is re-engineered it should include pharmacists at the stages that involve medicine to ensure their optimum use. This will embed the principle of gaining better value in the use of medicines well as improved patient outcomes.

We support a move towards payment for performance (quality) rather than volume for community pharmacy and would like to see this strengthened in the national pharmacy contract. An element of performance payment will recognise quality of service and improved clinical outcomes for patients.

Within the RPS, the EPB is leading a piece of work being undertaken between the RPS and the Royal College of General Practitioners (RCGP), which identifies area where pharmacists and GPs can work in a more co-ordinated manner to provide better patient care. The outcomes of this work will illustrate how closer working will benefit patients and the NHS.

 

4. Autonomy, accountability and democratic legitimacy

4.1

The EPB welcomes a healthcare service freed up to deliver healthcare to patients. We believe that care standards will be raised by the measures in this document but we are concerned that there appears to be little to direct commissioners to commission services that are required by the communities they serve. Any commissioning body will need to have a robust document that will inform their decisions, and we believe that the Joint Strategic Needs Assessment (JSNA) should perform that function. We would recommend that the Health and Wellbeing Boards (HWB) use the results from the JSNA to monitor that services commissioned in their locality meet the needs identified. There should be governance arrangements in place which ensure the ‘any willing provider’ model is fully supported and that GP consortia consider all providers in a transparent manner and so are not seen to favour their constituent practices. We believe that the Pharmaceutical Needs Assessment (PNA), currently undertaken by PCTs, should be led by the HWB and should be part of the overall JSNA.

4.3-4.6

The EPB believes it is right that experts are utilised to deliver key services outside the skill sets of GPs, for example the commissioning and monitoring of provider performance. It is, as yet, unclear what standards providers will be judged against. The EPB would like to see a consistent set of standards agreed amongst all potential providers and bodies such as the NHS Commissioning Board and HealthWatch. This set of standards should be used as a comparator for existing providers. Consortia must take the performance of service providers into account when re- awarding contracts.  New entrants into the market also need to be supported as they may not have any performance history.

It is unclear how specialist services which are currently commissioned across PCT boundaries will be commissioned in the future. Pharmacy specialist services which 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 NHSCB potentially offers a mechanism to commission specialist pharmacy services to a consistent definition and in a coherent manner across England. Specialist 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 as part of specialist services and within secondary care and this must not be forgotten as the proposed new structures develop.

There could be a potential loss of interconnections within NHS organisations moving forwards as new commissioners and providers take on their roles. Secure email systems such as NHS mail, shared training events and the culture of sharing information between departments may be lost. We urge the government to take steps to ensure that national and local connections that improve patient care are not lost to the new organisations.

4.7 - 4.8

As the new, proposed system of primary healthcare is introduced, the EPB feels it is essential to capture the expertise existing within PCT pharmacy teams. These teams working in both provider and commissioning arms provide essential pharmaceutical input into local strategic decision making as well as prescribing advice and work on medicines usage and formulary management. The effective utilisation of this expertise will be pivotal in the future success of primary healthcare. Therefore the EPB would like to see the skills of PCT based pharmacists being protected in this transitional period and will work to ensure that they are embedded into the emerging new models of care. These pharmacists ensure that drug budgets are within acceptable levels and that locally introduced formularies are suitable for the communities they serve.

4.10 – 4.11

The EPB endorses the NHSCB’s role and functions. In particular we support their role in the promotion of research involvement and the use of research evidence. However, the EPB would question whether “promotion” is sufficient, and would hope to see a more formal requirement for analysis, evaluation and research to ensure evidence based commissioning decisions. This should be made explicit as part of the NHSCBs leadership role.

We believe that the national pharmacy contract should sit with the NHSCB and would expect this to easily enable pharmacy services that meet the needs of all communities to be commissioned at a national level, as advanced level services or directed enhanced services. In particular the treatment of minor ailments, sexual health services (including emergency hormonal contraception, Chlamydia screening and treatment and contraception), Flu vaccination and NHS healthchecks.

Alongside more national services the EPB understands the need for a localised NHS with services commissioned by locally accountable bodies. In order for these services to be easily commissioned and to provide measurable and comparable outcome data there should be a set of national service frameworks acting as a menu from which local needs can be met. The RPS will play a key role in the description of good standards and outcomes, as well as the competencies required by pharmacists and pharmacy support staff involved in service provision. This will avoid the current problems of pharmacists being unable to provide enhanced services in neighbouring PCTs without multiple accreditations. Such processes have in the past proved to be a barrier to the delivery of quality services to patients.

We believe that the NHSCB will require strategic pharmaceutical input into the commissioning process; this should include the appointment of a pharmacist at board level.

4.17

The EPB agrees that local authorities should have new responsibilities regarding public health and health improvement. We also agree with the concept of a Health and Wellbeing Board. The EPB would like to see healthcare providers involved in the business of the Health and Wellbeing Boards, offering advice and support where relevant. We will be making a case for the formal inclusion of pharmacists on such local oversight bodies.

4.18-4.19

The Government’s moves to co-ordinate delivery of social and health care are long overdue. This document stresses that different bodies will ‘lead’ or ‘promote’ but doesn’t seem to wish to identify any one body to be responsible for agreeing a JSNA, for prioritising the results from the JSNA, for integrating the JSNA with commissioning, or for holding GP consortia to the priorities agreed from the JSNA. Results from a JSNA may identify several gaps in service provision locally. However, there may not be the skill set or financial capacity to deliver all of the identified services so there will need to be a prioritising process. We would recommend that the HWB carry out this role.

Whilst it is key for GP consortia to have independence to commission the services they feel are required, the EPB wishes to see a direct link between the needs identified in the JSNA and the services that are commissioned. The EPB would also like to explore further how commissioning services from a JSNA will work when GP consortia and local authority boundaries are not co-terminus. It is clear that the maximum benefits of joint working and local democracy are delivered from organisations that share boundaries. Confusing situations may arise where a local authority may have several GP consortia within its boundary, or GP consortia may be dealing with multiple local authorities, or both situations may occur in the same geography. This is inefficient and should be discouraged.

We are concerned about strategic planning as there does not appear to be any mechanism for this within the proposed new structure, an example of this is urgent care. There are also no mentions of risk management processes in place should the system fail.

4.24

The EPB believes that it may be necessary for GP practices to be service providers to their consortia; however we are keen to ensure there is a robust provider – commissioner split. Any service specification should be designed to avoid bias towards one particular profession or provider group.

4.27

The EPB accepts the inspection of providers as an important part of maintaining quality service provision, but we would like to see this inspection integrated with the existing inspection regimes to which all healthcare professionals are subject. Multiple inspection teams will cause expensive duplication, needless distraction and possibly a conflict in advice given to individual practitioners or the regulated organisation in which they work.  We would like to see appropriate regulation, rather than duplication, for the benefit of professionals and we are mindful of the cost of regulation to the NHS.

4.28

The EPB questions whether Monitor will have the capacity to fully investigate every occasion when suppliers have commissioned themselves without considering the needs of the patient first. There should be clarity around the mechanisms of local resolution, which currently rest with PCTs, to prevent excessive referral to Monitor.

4.31

We would support the role of the NHS in empowering staff and would like to see this extended to all those who provide NHS services, including contractors. We would like to see this approach delivered equitably for all healthcare professions.

4.32 – 4.34

The EPB welcomes the secure future of Medical Education England (MEE) and the role that it will play nationally in education and training. We are at present unsure about how MEE will lead education locally and will look forward to further consultation in this area later this year. The RPS are developing Local Practice Forums which could provide local input into educational leadership and operate as part of multidisciplinary deaneries, whilst drawing on and co-ordinating the educational expertise within the profession.

At present we are keen to ensure that the current funding streams for the education of pharmacists and their support staff within the managed sector is carried forward into the new NHS. SHAs have been instrumental in the management and routing of national funding in this area, if this role is taken up by GP consortia it is unclear how they will have sufficient expertise to ensure the most appropriate use of such funds. The RPS will take this opportunity to inform and advise, and lead on education and training across pharmacy. The white paper discusses the education and training of pharmacists, but does not mention the training of technicians or support staff which is also important, if not crucial to managing workload and ensuring patient safety. 

We are also concerned that the Centre for Workforce Intelligence has access to pharmacy expertise to inform and analyse and provide information about the complex pharmacy sector without direct input from within pharmacy. The RPS is currently working on a model to recognize career progression in all sectors of pharmacy. We would welcome the opportunity to take an active leadership role in workforce planning.

 

5. Cutting bureaucracy and improving efficiency

5.1

The EPB believes that better use of healthcare professionals across an integrated care pathway will cause a reduction in public spending. More efficient use of healthcare professionals by utilising them for those sections of the care pathway for which they are most suited will introduce real savings in healthcare.

Community pharmacy is highly accessible for patients of the NHS and those seeking to maintain good health with 99% of the population being able to access a pharmacy within 20 minutes by car and 96% by walking or using public transport.[3]  By encouraging the effective commissioning of services from community pharmacy, GP Consortia and Local Authorities (LAs) can make more efficient use of resources and assets to develop services which are truly local and responsive to the needs of communities.

Community pharmacy often sees the most vulnerable patients – those who do not access mainstream healthcare such as students, homeless, refugees and asylum seekers. They can and do provide bespoke services for these people and we would like that particular role to be strengthened and supported going forwards.

5.2

The new technology, to which the NHS is already committed, can introduce higher levels of patient safety, cut costs and simplify the patient pathway. There is an expectation by the pharmacy profession in England that it will be able to offer a more effective service to patients once they have access to relevant patient information, and to also write the actions they undertake to a central record.

5.3 – 5.4

The abolition of SHAs and PCTs and the subsequent reduction in management costs opens up opportunities to become a leaner NHS. However, there is risk that GP consortia will have to undertake a lot of this management to the detriment of their focus on patient care, or that a new bureaucracy will be created at the GP consortia level.

5.8

The RPS welcomes the drive to cut the bureaucracy involved in medical research and awaits the publication of the Academy of Medical Sciences independent review to inform developments on rationalised research regulation. However, given the extent of legislative change proposed in the White Paper the RPS would hope that this issue is given priority so that all stakeholders in research can benefit from streamlined processes that enable more rapid knowledge transfer (bench to bedside).

5.12 – 5.17

We support the continuation of the Quality, Innovation, Productivity and Prevention (QIPP) agenda and the resultant improvement in patient outcomes. Pharmacists have a particular role in the QIPP agenda as medicines are often the most expensive aspect of a care pathway and medicines usage is part of the majority of care pathways. Any process that takes an innovative view of a service would benefit from the inclusion of pharmacists expertise. 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.

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 [5].

5.14

The EPB wish to clarify the extent to which Monitor will regulate specific services provided by community pharmacies, further discussion will be put forward in our response to the “Regulating Healthcare providers” consultation.

 

6. Conclusion: making it happen

The EPB welcomes the Government’s decision to seek views and assistance from external organisations and offers the expertise of our pharmacist members to progress this work.

Like ministers, we see the main role of pharmacists as ‘optimising the use of medicines and in supporting better health.’ We would welcome active involvement in refining the proposals outlined in this consultation to develop solutions that work best for patients and maximise the use of pharmaceutical resources.

We are concerned that a big transitional gap may emerge during the transfer of roles, responsibilities and commissioning processes into the proposed new structures which could have a detrimental effect on the public’s health.

 

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References

1. National Strategy for Neighbourhood Renewal: Improving shopping access for people living in deprived neighbourhoods, 2000
2. Data taken from NHS Information Centre
3. National Institute for Health and Clinical Excellence (2009) Clinical Guideline 76; Medicines Adherence.
4. The Bow Group target paper. Delivering Enhanced Pharmacy Services in a modern NHS:Improving Outcomes in Public Health and Long-Term Conditions
5. Pharmacy Professional: October 2010. Lessons from Scandinavia and a drug dispensing machine.