Ten months on from taking over pharmacy commissioning and with Pharmacy First on the horizon, how are ICBs managing pharmacy as part of the system? And what does pharmacy think of their progress? Saša Janković takes a look.
It is looking like 2024 will be a year of more change for pharmacy. Last week, pharmacy minister Dame Andrea Leadsom said that ‘over 90%’ of community pharmacies have now signed up to deliver the Pharmacy First service launching in England on 31 January
It will replace the Community Pharmacist Consultation Service (CPCS) and consists of three elements:
- Minor illness consultations with a pharmacist
- Urgent repeat medicine supply – previously within CPCS
- NHS referrals for minor illness – previously within CPCS
It is intended to increase access to prescription-only medicines (POMs) for seven common conditions – impetigo, infected insect bite, sinusitis, sore throat, earache, shingles and uncomplicated UTIs in women. The aim of the service is to address funding challenges for the sector and improve access to healthcare for patients in primary care settings where options are limited.
However, as community pharmacy prepares for the launch of Pharmacy First, this also creates training and awareness needs within the wider system that add to their ongoing workload burden.
The launch of Pharmacy First is the latest in a series of changes for pharmacy. It was not even a year ago that integrated care boards (ICBs) took on the responsibility for commissioning pharmaceutical, general ophthalmic services and dentistry (POD). The shift came on 1 April 2023, as part of a range of commissioning reforms initiated by the Health and Social Care Act 2022, with NHS England retaining overall accountability for the discharge of the POD functions, as well as for primary medical services.
The aim of bringing together management of these primary care functions at a system level was to enable a stronger voice for primary care providers, patients, the public and other key stakeholders while unifying previously siloed sectors of primary care.
Janet Morrison, chief executive of Community Pharmacy England, has called it ‘more ambitious and joined-up commissioning’ and one of the key factors in developing local systems, adding that ‘failure in delivering this vision to safeguard community pharmacies is simply not an option’.
However, in the 10 months since the change, pharmacy leaders have expressed concern as to how community pharmacy is meaningfully contributing within this collaboration – especially considering the under-utilisation of pharmacies as the primary point of call for local care services – while integrated care system (ICS) leaders, too, are under pressure to reduce their running costs by 30% over the next two years.
Yousaf Ahmad is chief pharmacist and director of medicines optimisation at Frimley Health and Care integrated care system. Last year, he chaired roundtables for thinktank Public Policy Projects (PPP) about the role of pharmacy in the system, and how devolved commissioning was working so far.
Noting that pharmacy is ‘frequently penalised for sub-optimal outcomes that are often the result of poor patient compliance, despite medicines being correctly dispensed’, the resulting report found delegates said commissioning and contracting mechanisms must be ‘rooted in optimal outcomes’, and that the introduction of ICSs presents new opportunities to implement this, with a ‘clear alignment’ between the principles of ICSs and outcomes-based commissioning that reflect the population covered, the scope of services and the configuration of associated providers.
Unsurprisingly, Yousaf sees medicines optimisation – and pharmacy’s role in this – as vital to connecting patient wellbeing and the broader health and care ecosystem. As a result, Yousaf says pharmacy is ‘uniquely positioned’ as ‘a strategic asset’ which can help ICS leadership achieve key objectives of integrated care and redefine population health management strategies and combat health inequalities.
However, he stresses that ICSs must leverage all assets at their disposal to achieve optimal outcomes.
‘Connecting pharmacy teams with other elements of primary care and indeed the broader health and care sector is essential for driving pharmacy-led transformation and the diverse components of ICSs must come to understand and harness this latent potential,’ he says.
In his role as chief pharmacist at Lancashire and South Cumbria ICB, Andrew White is regularly involved as a professional adviser in groups and committees and offers individual support to healthcare leaders. Current areas of focus for his ICB include developing a medicines strategy in development – which he says will be published in the first half of 2024 – and sorting out better discharge of patients in relation to medicines.
‘We are implementing a system-wide approach to referral to pharmacy at discharge, which will then mean we have a better uptake of the discharge medicines service (DMS)’, he says, ‘and we are working with trusts to improve discharge communication to meet patient and primary care needs.’
In the more immediate term, White says the ICB is ‘actively encouraging’ community pharmacists to get involved in the independent prescribing pathfinder programme and Pharmacy First, which ‘will improve access and care closer to home for patients in Lancashire and South Cumbria’.
In addition, ICBs continue to face the challenge of delivering their ambitions to transform local services while working within current regulatory frameworks – an area where Ben Squires, head of primary care at NHS Greater Manchester Integrated Care, predicts all ICBs are likely to experience challenges.
‘For ICBs to be able to make the most of POD delegation and opportunities for local service development and integration, it is important that NHS England allows them to maximise the flexibility within existing regulations and contractual tools but also contribute to the future design of regulatory arrangements, ensuring that the ICBs and local systems have expertise and skills in this area,’ he says.
For its part, NHS Greater Manchester ICB has encouraged more collaboration at the neighbourhood level working across primary care services and with other local partners such as the voluntary, community and social enterprise (VCSE) sector. Luvjit Kandula, director of pharmacy transformation at Community Pharmacy Greater Manchester, gives the example of an increasing level of integrated working between GP practices and community pharmacy in her area, which she says has helped to build an understanding and awareness of the challenges both sectors face.
‘The ongoing engagement with localities and practices to implement GP CPCS and other advanced services has helped to develop open communication channels to resolve challenges through better communication,’ she says.
‘There is, of course, variation in engagement, and issues such as the medicines shortages are causing additional workload and strain to all parts of primary care, but we have opportunities to engage with the ICB, locality boards, practices and GP boards/LMCs to work together and resolve ongoing issues.’
Tensions and collaborations
A flip side of collaboration, and another area that has given rise to reports of some tension between pharmacy sectors in the system, is the additional roles reimbursement scheme (ARRS).
ARRS was introduced in England in 2019 to enable PCNs to create bespoke multi-disciplinary teams, funding 12 new roles, including clinical pharmacists and pharmacy technicians, with the aim of recruiting 26,000 additional staff into general practice by 2024. Early last year, the Government announced it had already beaten this target, adding 29,103 additional staff into GP practices, prompting concern from some in the community pharmacy sector.
The Company Chemists’ Association chief Malcolm Harrison said the recruitment of pharmacists via ARRS should stop ‘immediately’. Even the Government-commissioned review of ICSs, published in April 2023, mentioned the ‘unintended consequences’ of recruiting community pharmacists to general practice, adding that ‘the national requirements and funding of ARRS roles for community pharmacists within PCNs has on occasion exacerbated the problem of a general shortage of pharmacists’.
Nonetheless, there are plenty of examples of PCN pharmacists and community pharmacists working well together within systems. Vanessa Sherwood is lead pharmacist at Weymouth and Portland PCN – a network with a population of around 78,000 people and 17 pharmacies.
‘Thanks to a fantastic, hard-working small team of pharmacy technicians in the PCN, we have improved how we work with the community pharmacies as we develop our service,’ she says.
The technicians lead the work, she explains, and have organised two large evening meetings for all the pharmacy staff, local GPs and some ICS and secondary care representatives.
‘They also support individual practice meetings with the pharmacies closest to them and have set up a PCN community pharmacy WhatsApp group that is very useful for shortages and alternative requests. Even better, the pharmacies that are engaged with this use it to easily organise these things amongst themselves sometimes,’ she adds.
The technicians triage the team email inbox, where pharmacies can also send alternative requests and any queries they may have about prescriptions, and try to hold regular meetings with the local pharmaceutical committee’s PCN reps as a way of addressing any issues.
‘It is usually quicker for the community pharmacies to contact us now than going via the practice where the request may bounce around before it finds the right person’, says Sherwood.
She adds: ‘There are occasionally tensions, of course, but this is usually as a result of a small number of the multiples’ pharmacies who are not supported to engage in the processes we are all using across the PCN to make sure that patients get the medicines they need.’
Community pharmacy integration
Raj Matharu is chief executive of Community Pharmacy South East London, where one of his focus areas is developing a leadership programme for community pharmacists, which prioritises a neighbourhood-centric strategy.
‘In my role, I work collaboratively across community pharmacists in the neighbourhood to support and assist in providing NHS services, but we still don’t have enough community pharmacy leaders and, at meetings, I’m usually outnumbered,’ he says.
Matharu says more pharmacy leaders are needed in neighbourhood place and system since GPs will then see more of the pharmacists they usually work with and that will foster integration and relationships at system level.
‘That’s why I engaged with my ICB leadership team and together we created a plan for what we call community pharmacy neighbourhood teams which, as it matures, will develop leaders at a neighbourhood, place and system level and then will start engaging and going to meetings that I alone cannot go to, creating even more partnerships,’ he says.
Matharu’s community pharmacy neighbourhood leads also make use of a WhatsApp group for peer review and support.
‘At the moment, it’s restricted to community pharmacy PCN leads so they can get a bit of confidence in the group. Eventually, I want to start engaging with practice pharmacists, PCN pharmacists and hospital pharmacists, creating an even greater clinical network, especially since the pharmacy foundation year is going to be multisector very soon,’ he says.
Community pharmacist Nick Kaye is superintendent director of Hendra pharmacy in Cornwall, as well as the PCN lead for Falmouth and Penryn. He says that when working with directors of primary care, they ask him to ‘tell us what we don’t know’.
Describing community pharmacists and the LPC as ‘critical friends to the ICB’, Kaye says ICBs in their system are ‘asking questions about what stuff means so they can avoid any unintended consequences’. He says this is useful when ICBs are making potentially contract-changing decisions that could affect the local system.
‘So, a really simple example would be asking us what changing a prescription length for a patient actually means, both for them and from a cost-effective perspective,’ explains Kaye.
With the launch of Pharmacy First, Kaye says this connectivity between the front lines of primary care is ever more vital.
‘We’re trying to make sure that our system is as ready as it can be, and that’s been a key area of focus for us. When it comes to system communication, what Pharmacy First is not is as important as what it is. It’s these types of things, as an LPC or at local level, which we have a responsibility to help support and demystify within the system,’ he says.
Michael Lennox, National Pharmacy Association (NPA) integration lead, says while it’s ‘still early days’ to judge whether the shift of power to ICBs will help maximise the contribution of community pharmacy to improved health and social care, the NPA remains ‘committed to supporting pharmacies to engage at systems level’, as this offers ‘the best chance’ of introducing innovation and developing integrated clinical services.
‘The Fuller and Hewitt reviews highlighted significant opportunities for community pharmacy in primary care and prevention’, says Lennox, ‘and that applies every bit as much today’.