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Future models of primary care

Future models of primary care
3 June 2014

The latest meeting of the National Primary Care Network

The latest meeting of the National Primary Care Network

It’s clear that the current model of primary care is not sustainable. With an ever increasing funding gap, an ageing population and an emphasis on provision in primary and community care, the sector is becoming more and more squeezed. 
The National Primary Care Network (NPCN) met at the Royal Pharmaceutical Society headquarters in London to address this very question. Dentists, nurses, optometrists, pharmacists, GPs and other healthcare professionals listened, shared, discussed and disagreed. 
Although no definitive answer was reached, the sparks of best practice dispensed could ignite changes across the country. 
Alliance and outcomes-based contracting
NHS England has defined alliance contracting1 as “separate contracts with individual providers but with shared objectives”. Potential benefits include improved efficiency and pathway co-ordination, however, there is a need to be “clear on where responsibility lies for delivery” and “strong working relationships” between providers are necessary, NHS England claimed. 
Outcomes-based commissioning, on the other hand, sees payments for individuals based on achieving good outcomes. 
Deborah Jaines, NHS England Head of Primary Care Policy said that England does not currently have a framework for alliance or outcomes-based contracting which would provide guidance for how the schemes could be implemented locally.
However, guidance on flexible forms of contracting is due to be released later this year. But Jaines said that although it would be “exciting” to move towards alliance contracting, ultimately the NHS is “an awful long way off”. 
Mukesh Lad, Chairman of Pharmacy Northamptonshire points out that having no guidelines is currently a “big stumbling block”. He said templates, which could be easily used by Local Pharmacy Committees (LPCs), could make it easier to engage clinical commissioning groups (CCGs) to commission for local priorities. 
Dr Leon Douglas, Head of Clinical Engagement at Croydon CCG said that while there is a lot of enthusiasm on the frontline to utilise ideas such as alliance contracting, CCGs budgets are already tight. 
“I think it’s perhaps difficult for [CCGs] to consider what money they can put into primary care as well because they are being squeezed from both directions. I’m not saying it’s wrong to put into primary care but there is only so far the CCG allocations will go.” 
Although Jaines agrees that the NHS budget is stretched, she has “faith that if you put more money into primary care that it prevents secondary care interventions and expenditure further down the line” and that the argument for change needs to be made to the area team or CCG.
However, Dr Charles Alessi, Chair of the National Association of Primary Care, felt that the issue was whether NHS England’s area teams are experienced enough to handle new models of contracting. 
“There are concerns around the sophistication that is required for area teams to actually manage this process because equitable mediocrity is something people have been talking about since around 2008 or 2009… It is very difficult to create an environment where people are allowed and actually encouraged to do more for populations,” he said. 
Ending the discussion, Steve Foster Pharmacy Superintendent at Pierremont Pharmacy said: “Everybody is in agreement that things can’t continue as they are. The £20bn challenge we had a couple of years ago has grown to £30bn and it will continue unless we do something about it. 
“What we could do is [begin to look from] a population health perspective, but that can only happen in a collaborative way. Charles [Alessi] and James [Kingsland] in particular have been very supportive of this collaborative working model, but we are limited at the moment by our contract, in that we need an outcomes-based contract which fits in with the other contractor professions. Delivering our contract should be helping to deliver GMS”
Pharmacy: Providers of care? 
NPCN members, although vehemently disagreeing on the details, were clear that the future of pharmacy is in delivering direct patient care. 
In a presentation that tipped the room towards in-depth debate, Catherine Picton (pictured below) called on pharmacists to raise patient expectations. “We must be loud, clear and consistent with the message that pharmacy provides patient care,” she said. 
 “Pharmacy has to continue to develop direct patient services. The more patients experience services as being delivered by pharmacists, with pharmacists as clinical providers, the more you come to expect that. It’s about raising expectations,” Picton added.
However, she felt that the way to increase pharmacy’s role in provision of care is to “encourage pharmacy to be commissioned in a much bolder way”. 
Ash Soni OBE, pharmacist and clinical network lead at NHS Lambeth conceded that pharmacy has been slower than the rest of the health service at “recognising both the challenges and the opportunities” currently faced. 
For him, it is clear that contractual arrangements must be “broken down” in order to make population health central to everything done in primary and community care – through an overarching contract. 
At Nethergreen Surgery pharmacists have been employed on a part-time basis for more than ten years, GP Principal Dr Eithne Cummins revealed. At her practice, she said, they “recognise the value” of pharmacists’ knowledge. 
“We have considered having a pharmacist as a partner in our practice, and I think that day will come. It’s a very simple way of trying to incorporate and integrate within the community setting. You don’t even have to consider contracts – you can get around that. 
“More than anything you need the cultural change towards working together. Having an integrated dispensing pharmacist is not that hard! But we have to consider the opportunities we have within the existing framework.” 
Ash Soni agreed that having pharmacists at diagnosis point for long-term conditions is one way to encourage more effective use of medicines from patients. 
“A pharmacist can talk through the medicines and non-medicines options. This could make a difference to lifestyle and to outcomes, because the patient is in control and can then buy into the offer in a way that we don’t do well currently. 
“It’s one of the reasons why the linkage and integration from federations could help us work more effectively than we currently do.” 
Bexley CCG chair Dr Howard Stoate felt that Soni’s vision of pharmacists talking patients through new diagnosis is the way forward, but agreed with Patel that there is currently no incentive for change. 
He said: “In my area we had an anticoagulation contract, but the only bidders were GPs. The pharmacists, although there were a few toes dipped into the water, essentially didn’t want this £500,000 contract. 
“Pharmacists aren’t coming forward, and I think it’s because they’re not frightened enough yet. I think in five years’ time community pharmacy will be dead because a company like Amazon will have taken over a medicine’s management service which is better than anything we have in this country.” 
According to the Royal Pharmaceutical Society’s report, Now or never: Shaping pharmacy for the future,3 the business model of community pharmacy is being challenged by technological developments that enable new forms of dispensing, “such as the use of robotics”, which has become widespread in some countries, such as the Netherlands. 
With reference to this, Dr Stoate said he has seen services in America which deliver medicines within two hours, offering 24-hour support for patients on a nurse-led telephone line. According to Dr Stoate, this costs a fraction of the current pharmacy service. 
“Pharmacy has only one future, and that future is clinical services – things you can’t get online. Unless pharmacists change rapidly there will be no community pharmacy. Unless they do, pharmacies will go the way of bookshops.” 
Premises: Physical or virtual? 
Premises has become a key issue in primary and community care, with NHS England halting investment in GP premises while a “consistent” national process to evaluate funding bids is developed4. 
When the process comes to a close, clinical commissioning groups (CCGs) and area teams will have solid advice on which to base future planning. But at the NPCN meeting, Graham Roberts, chief executive officer of British-based property business the Assura Group, said that new buildings which bring together primary and community services could revolutionise care for patients. 
“I feel very strongly about developing new buildings, bringing all the services we’ve been discussing today under one roof,” he said. “It’s a way of transforming the entire way in which the services are delivered, and importantly it’s what patients want – to have a beacon of the community which patients recognise as a medical place, rather than a converted house.” 
However, other NPCN members were not convinced that a physical home for community care would bring about transformational change. 
Dr Hasan Chowhan, board member and urgent care lead at North East Essex CCG recognised premises as an important issue, but said there is no need to be “so fixated on locations”. 
He said: “Care can be delivered anywhere. The fundamental step that’s stopping us [from working together] is the sharing of data.” Citing reports from the medical press and the nationals5, Chowhan noted that one GP in particular is writing to patients, urging them not to share records through NHS England’s scheme. 
“I think that’s a real block. At the minute, the urgent care system is a waste of space if you can’t see clinical records. Healthcare professionals are treating people, but they have no idea what their long-term condition care is like! If patients don’t understand that if we could all see their records their care would be 200 times better, we won’t move anywhere.” 
Dr Luigina Palumbo, GP and clinical chair of East Riding of Yorkshire CCG believes that the future of premises is virtual. She said: “We thought that hospitals were the answer once upon a time – I’m concerned that we might think these One Stop Shops will now be the answer. 
“Yes, I think we should all be working together, but it doesn’t have to be surrounded by walls.”
1, 2. The NHS Standard Contract: A guide for clinical commissioners, NHS Commissioning Board (NHS England) 4 February 2013. Available at:
3. Now or never: Shaping pharmacy for the future, Judith Smith, Catherine Picton, Mark Dayan, Royal Pharmaceutical Society, November 2013. Available at:
5. GP fears losing job over pledge to keep patient data private, Claire Carter, 5 February 2014, The Telegraph. Available at:

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