The new contract is dead: let us now get the future for pharmacy we want
Community pharmacists need a policy framework from the Government that sparks innovation and experimentation, and frees them from being told how to work
“This world… belongs to the strong, my friend! The ritual of our existence is based on the strong getting stronger by devouring the weak.” — Ken Kesey, ‘One flew over the cuckoo’s nest’
Pharmacists and the wider healthcare sector are being asked their views via a “Call to action” by NHS England on how community pharmacy can improve the primary care sector (PJ 2013;291:618).
There is a general tendency in life to want to do what others have done. It is an understandable, but short-sighted, impulse. One of the great things about being a pharmacist is that you have the opportunity to learn from doctors and see what you want to imitate — and, more importantly , what you want to skip.
Away from pharmacy, British Telecom has recovered from a missed opportunity. Despite its plans to the contrary and its focus on “traditional technology”, namely, landlines, the right thing (mobile and broadband) has happened. Community pharmacy must similarly make sure it does not miss out on opportunities for the future.
Having served on several national bodies, I predict that pharmacists will say: “What the doctors can do is what we can do … only cheaper.” That is linear thinking and adds nothing to innovation, to professional development or to meeting the needs of our populations.
Should we follow someone else’s well trodden path? No. We need to apply a “leap-frog” mentality and find a different path to a better future. Education, healthcare and infrastructure will all change. The key is to leap-frog the competition, not to copy it.
So, how do we go about creating this alternative path of leap-frogging the competition. We must use the creativity of the profession and the energy of its innovators to stimulate new thinking, practice and politics. The NHS needs new solutions and, hopefully, it will listen to pharmacists, whose intellectual capital is what is underpriced and underappreciated at the very time their skills and knowledge are much in need.
It is easy to say “Let’s look beyond today and plan for the future” and then, as with the “new contract”, be prescriptive. Who wants a protocol-driven practice and bureaucratic burdensome future? Not pharmacists.
Not only is copying the competition a mistake, but rushing to do specific things is a big mistake.
Technology advances in ways that are unpredictable and the human response to technology, too, is unpredictable. Is it wise to rely on plans that presume to see the future too clearly? Strategic planning is almost invariably misled, often by vested interests that see no future in the change or moves towards a change that benefits them.
So, rather than trying to predict the future, we should be trying to fit into the future as it happens. Instead of setting out 10 concrete goals, we should encourage one broad direction and adopt an evolutionary mindset. That way, as the world and healthcare changes, we can adapt as breakthrough technologies come along.
Former US?president John F. Kennedy set the goal to land a man on the moon and return him safely within a decade; he did not prescribe how it should be done. Similarly, we should set a noble goal that serves humanity and adds value where no other professions can because we have leapfrogged them.
The healthcare system in which we operate will be different in the future. The biggest changes will be around patient empowerment, responsiveness, personalisation and technology. Who provides a service will be less important than how it is provided. I believe that medicines safety will increase in importance and will save costs, enhance pharmacists’ reputations and reduce human misery. Forget small public health and clinical initiatives and copying others, I say. Think about empowering patients and facilitating safe self-care and independent living as real goals.
What are some of the implications of that? The first is that we will need a different type of pharmacist and infrastructure. Imagine a healthcare system run on smartphones and high quality reliable information customised to your needs. Imagine all routine diagnosis, new learning and support being provided via your smartphone as and when you need it, without delay and at an affordable price.
A second implication of the spread of technology is fewer pharmacies but importantly not the need for fewer pharmacists. This is critical to appreciate if we want ensure that pharmacy has a future.
Well educated, motivated pharmacists can use their skills and knowledge to improve care and responsiveness. Could they provide high quality personalised care and help patients get the best out of their medicines while physical dispensing is carried out robotically. Could pharmacists be more proactively case finding and clinically assessing patients, particularly those suffering from minor ailments or stable long-term conditions?
I believe that the human and intellectual capital of the profession, and the reputation of lo cal community pharmacies, are worth an awful lot. So, there is no need for us to be chained to the past.
A shift toward a knowledge-based service would cut resource usage in a major way, lessening the need for capital investment and reducing expenditure in the NHS. Pharmacy services would become more affordable; the usage factor would be much higher, so the payback time would be much shorter.
We need pharmacy to be more adaptive to local need rather than simply adding capacity. We need to make a mas sive investment of time in a new plan to improve self-care. We should have a dynamic system that adjusts to a world without boundaries and responds to the growing demand for preventive care, healthcare and safe pharmaceuticals. We do not need a centrally driven prescriptive system like what we have at present, which stifles innovation, allows new competitors to enter the market and introduce economies of scale, and kills the human spirit.
If these assumptions are correct, the future of the profession will look different from the one that exists today. Take it from me: the new contract is dead.
Learn from others
What happened to BT in communications, when it changed from an old-fashioned service provider to a modern and growing giant, can happen to us, too. So why not learn from the telecommunications experience and apply the lessons to pharmacy? The precise outcome may be different. The main thing is to create a regulatory, educational and investment climate to support the right broad policy goals (access to pharmaceutical expertise from pharmacies on smartphones rather than lock everyone into specific investment in newer, fewer buildings).
In a nutshell, we do not know who the future winners are — and it would be foolish of the Government and the Pharmaceutical Services Negotiating Committee to attempt to determine that. But, with our help, they can try to set the groundwork.
This is not just about waiting for the right climate to advance. I sense that the Government is beginning to think with an evolutionary mind-set, which means that it is seeking to encourage rather than demand. Incentives and standards must be used to push in broad directions rather than to force specific solutions.
Pharmacy has a major opportunity to reposition itself to meet the needs of society — thanks to the profession’s innovating pharmacists, its easy access and its massive market — and to change the rules of our future development.
The “Call to action” initiative favours distributed development and a more level playing field. This is our chance to get rid of the morale sapping, rigid and centralised system that favours fewer, bigger players. Every policy contains some kind of bias in one direction or another. The question is: what do we want to bias the future pharmacy system towards? Knowledge or products? Like other products, pharmaceutical products are increasingly available online. Knowledge, however, is relatively within our control.
The environment is changing rapidly. We have no option but to alter the bias of the future health system toward change, flexibility, and adaptability. It is in the interests of pharmacists to foster what is called “innovation capitalism” rather than “incumbency capitalism” Incumbency capitalism relies on generous depreciation and investment capital with rules that favour big, established players; innovation capitalism favours groups of people with ideas who are willing to experiment and create new services and products.
The shift to an online world is changing communications and education, and is slashing costs and transforming traditional approaches to teaching and healthcare. Pharmacy should take that and personalise the service it provides for better outcomes in health leading to independent living.
Internet start-ups need to change continually. For example, Pinterest went through 300 evolutions before it caught on. It might be the same for self-care pharmacy. It will not be perfect at first, but it will continue getting much better.
I believe such systems with pharmacy-based care packages could eventually replace around 80 per cent of doctor visits and deliver results with a better and more consistent quality of care. Pharmacy needs to leap-frog into that system.
The future will avoid the need for patients to visit pharmacy premises. With the right authentication system and a new digital-reputation system — like that of an eBay trader — a lot is possible, including a personalised, confidential, responsive and evolving system.
Despite pharmacy’s well known problems, I am optimistic. Why? Because new ideas are more important than capital or political power in the digital world.
In conclusion, we have to develop a leap-frogging mind-set, and get better organised at using technology to outsmart the political structures that hold us back. We have to urge the Government to give us a better policy framework that sparks innovation and experimentation, that frees us from being told how to work and that encourages us to do the right thing.
Let us mobilise our spirit and, through the “Call to action”, create the future that we want.
Hemant Patel is secretary of the North East London Local Pharmaceutical Committee.
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.11133213
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