The restructured NHS in England: what is new and how does it affect you?
New structures for the NHS came into being on 1 April 2013. What can pharmacists do to make the most of new opportunites and minimise any potential threats?
Ash Soni Clinical network lead, NHS Lambeth
The new NHS is upon us. Can you tell the difference?
If you are a patient, the answer, in terms of care, is probably “no”. If you are a GP, the answer should be “yes”. If you are an NHS manager, the answer is “yes”. If you are a hospital pharmacist, the answer is probably, at the moment, “no”. If you are a primary care pharmacist, the answer, if you work for an NHS organisation, is “yes” but, if you work in the community, the answer is probably “no”. If you are a community pharmacist, the answer, if you are an owner, should be “yes” but, if you are an employee, is probably “no”.
Why so much variation? The reasons should be that at this stage most of the changes affect structures and who commissions what rather than outcomes or providers. Therefore, the changes should be visible to commissioners and provider organisations rather than to individual providers or patients.
Should pharmacists be bothered? Proprietors need to understand what the changes mean and their significance. All other pharmacists need to be aware of the impact on their employer and become knowledgeable of who does what, why it matters, and what they need to do.
What should I do now?
Proprietors need to make sure all their claims for locally commissioned services are submitted as quickly as possible. Since primary care trusts no longer exist as statutory bodies they cannot pay any outstanding accounts and therefore all monies due have been accrued centrally to make all outstanding payments. This means claims are likely to take longer to settle because there will be fewer staff processing the claims and making the payments. Also, the amount of money accrued is based on best-guess estimates and there is a risk that if insufficient monies have been accrued late claims are more likely to be rejected, particularly where service specifications give time limits for submitting claims.
Pharmacists practising in the community need to make sure that all patient group directions and all service specifications are valid and extended. Where there appears to be any confusion, they should check whether a termination notice was served, as required in the service specification.
What are the new commissioning organisations responsible for? For community pharmacy the most important is NHS England (until now known as the NHS Commissioning Board) because this is the organisation that has taken over all the primary care contracts, including the community pharmacy contractual framework.
However, the ability to see increased revenues from here will be down to the Pharmaceutical Services Negotiating Committee being able to negotiate changes to the contractual framework. The Royal Pharmaceutical Society should see an opportunity to develop its work with the Royal College of General Practitioners to discover how the two professions could work in a much more collaborative way to support the professions in creating contracts that work synergistically.
NHS England will control about 40 per cent of the total health budget. As well as primary care it is responsible for commissioning prison health services, military health services and specialist services, so all pharmacists working in these sectors will be directly affected by its decisions.
The biggest part of the health budget, approximately 55 per cent, will be managed by clinical commissioning groups (CCGs). Their commissioning responsibilities are dominated by acute services and community services but they also have control of prescribing budgets. Therefore they will impact on a significant part of the pharmacy profession.
However, just to add to the system fragmentation, they cannot commission anything designated a pharmaceutical service. Therefore, any services that pharmacists wish to provide for CCGs must be through the “any qualified provider” (AQP) route or through a collaborative integrated care route. The challenge for being an AQP will be to have the right skills and capabilities to meet the service specification. An example, where pharmacy could provide under AQP, would be anticoagulant services. This could also prove a real opportunity for all sectors of pharmacy to work together to produce the most effective outcomes.
The challenge for collaborative working will be to demonstrate the value that pharmacists provide in the care pathway that someone else is less able to do. An area where pharmacy has demonstrated its value and improved outcomes is in improving patient use of inhalers. Working with GPs and practice nurses there is an opportunity in supporting a more collaborative approach with the value outcome of reduced hospital admissions.
The final 5 per cent of the budget sits with local government in public health. This is where the greatest opportunities for pharmacists are likely to be since it is an area where community pharmacy has already demonstrated its value.
Smoking cessation services, emergency hormonal contraception, chlamydia screening, NHS health checks and healthy weight services are all examples of areas in which pharmacies have delivered improved outcomes. However, the challenge will be for pharmacy to continue to deliver outcomes and value because local government is likely to look to other providers, such as voluntary groups and charities, to support and deliver these services if they can demonstrate better outcomes and value for money.
Within the new structures there are a number of other new bodies that pharmacists should know about. The first, and most important to engage early, are health and wellbeing boards.
These are where all the new commissioning organisations come together. Therefore, this represents an opportunity for pharmacy to show how it can support the breadth of health and social care and help improve patient and public outcomes. These boards have meetings in public and pharmacists should find out when these meetings are being held and ensure they attend.
While there they should take any opportunity during discussions to ask questions and demonstrate the valuable role that pharmacy must have in future care. From a personal perspective I attended the most recent meeting of my local board and received strong support for the important role that pharmacy should play. As a consequence I have been asked to set up a workshop for pharmacy to showcase the services that it can offer locally.
There are networks, including strategic clinical networks (SCNs), which will look at particular areas of care to reduce variation and improve outcomes, and local professional networks (LPNs), which will advise on the commissioning of pharmacists, optometrists and dentists in specific services.
SCNs should include pharmacists if there is to be a truly integrated model because medicines are a significant part of all areas in which these networks will operate.
LPNs should be a real opportunity for pharmacy to get together as a whole profession and show how it can support the delivery of better outcomes for patients and public. An example would be in diabetes care. By bringing together the different sectors there is an opportunity to enhance the continuity of care that patients receive. Ensuring that academia and industry are also included should enable LPNs to collect the data and produce robust evaluations of the role that pharmacy can play in health and wellbeing.
There is currently a real problem here. In setting up the new structures there is a significant lack of money for LPNs. This is worrying because it indicates that NHS England has not seen the value that these could offer and therefore has only provided token funding.
The challenge for pharmacy is that if it does not invest time and effort it risks being excluded from the redesign work and therefore not being able to provide services for which it has significant skill and capability. I would encourage pharmacists to support LPN chairmen as they are appointed but to press any contacts they have within NHS England and the area teams to recognise the potential value and invest more resources in LPNs.
Another new organisation is Health Education England (HEE), which will deliver some education and training centrally. However, the vast majority will be commissioned more locally through local education and training boards (LETBs). LETBs will have flexibility to invest in education, training and ongoing professional development to support local priorities in innovation and development of the health workforce. These offer real opportunity to help develop the skills and capabilities of pharmacists, technicians and the wider support workforce. Historically, there has been a clear route for investment in pharmacy in the managed sector.
This, however, has not been the case for community pharmacy and its workforce. The Centre for Pharmacy Postgraduate Education has provided training for pharmacists and technicians but not for the wider workforce. This has not included salary support to enable employers to release their pharmacists, technicians and staff without significant cost to the business, a situation that should be improved by LETBs. The challenge will be to show how investment will help deliver better outcomes but pharmacy must make a strong case for investment to develop the workforce. This may also be a route to enable pharmacy to develop the skills and capabilities required for services delivered via AQP. A number of LETBs are also developing training based around care pathways.
Again, pharmacy needs to be included within these multidisciplinary teams and needs to ensure it promotes the value in being engaged in these developments. I am working with my local LETB on the development of multidisciplinary community training hubs. Additionally I am looking for the LETB to invest in the development of clinical leaders, particularly including pharmacists.
The last organisations I want to cover are the academic health science networks (AHSNs). These were created to improve patient and population health outcomes by translating research into practice and developing and implementing integrated health care systems. They need to be fully inclusive and therefore must seek to engage pharmacy in their work. These also have access to money and this should be seen as an opportunity by pharmacy to have new methods of innovative care tested, evaluated and, if successful, widely implemented. Pharmacists need to understand the priorities of their AHSNs and see how they can demonstrate their ability to improve outcomes through innovative practice.
Threat or opportunity?
Overall, should the new system be viewed as a threat or as an opportunity? There are significant threats within the new system which could lead to pharmacy failing to develop the services that it can offer. However, there is a need for the new organisations to show how they are different and how they will lead to improved patient and public outcomes. I believe this offers significant opportunities for pharmacy but pharmacists need to seek and engage with them proactively.
Pharmacy has a real opportunity to act as a single cohesive profession that understands how it can integrate to provide high-quality, continuous care across the system.
Citation: The Pharmaceutical JournalURI: 11119474
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