Changes to NHS structure: how will it affect the future of pharmacy and you?
Are you familiar with the reformed NHS structure? Kathryn Moffitt and Christine Wassef help you digest the complicated changes, which you need to learn as part of the registration assessment syllabus.
As preregistration trainees in 2013–14 you are entering a workforce on the back of great legislative change to the NHS. So what has changed since you were an undergraduate and how will it affect your future role as a pharmacist?
The new structure
Since the NHS was founded in 1948, it has undergone various reforms. Most recently, the Health and Social Care Act 2012 introduced significant and extensive changes to the structure of the NHS. As of 1 April 2013, primary care trusts and strategic health authorities ceased to exist, and have been replaced with an intertwined infrastructure of commissioners and support units. Clinical commissioning groups (CCGs) and NHS England have taken on commissioning responsibilities, with public health commissioning being transferred to local government. With this NHS reform, pharmaceutical services’ commissioning has also faced a few changes.
See diagram below of the new NHS commissioning structure (first published in PJ 2013;290:368)
(Download the simplified diagram as a PDF)
Clinical Commissioning groups
Across England, 211 CCGs are responsible for £65bn of the £95bn NHS commissioning budget. The aim was to transfer responsibility for commissioning decisions to GPs at a local level to improve healthcare services for their patients. CCG boards are predominantly made up of GP members, along with at least one member from secondary care, nursing and the general public.
All GP practices must be members of the CCG in their geographical area. Services commissioned by the CCGs include planned hospital care, rehabilitative care, emergency care, community health and mental health. This includes medicines optimisation services provided by pharmacists. All local services are commissioned by CCGs are under a standard NHS contract. In other words, services commissioned by CCGs will be awarded to the most suitable provider, and pharmacy needs to demonstrate its ability to provide high quality, consistent and good value services.
NHS England is responsible for commissioning £27.2bn worth of services nationally, including specialised services, primary care at general practice level, dental services and community pharmacy. This structure is responsible for promoting a comprehensive health service. Part of its responsibility is to oversee CCG operation, ensuring quality and safety. NHS England operates locally through 27 area teams (ATs). ATs are responsible for commissioning of pharmaceutical services provided by community pharmacy, which are the three-tiered essential, advanced and enhanced services.
Local professional networks
ATs do cover wide geographical areas and provide commissioning to various services and professionals. As such, local professional networks (LPNs) have been formed to provide a clinical input into local commissioning decisions. Each AT is supported by three LPNs, each representing pharmacy, dentistry and optometry. The pharmacy LPN supports ATs with the development of pharmaceutical needs assessment, which influences decisions on the types of services provided by local community pharmacies to meet local needs.
Commissioning support units and clinical senates
To ensure informed commissioning decisions are being made, the CCGs and NHS England have various supports, with the appropriate expertise, to draw on when necessary. Newly developed commissioning support units (CSUs) and the clinical senate fulfil this role. The CSUs provide technical support, including contract negotiations and management, while the clinical senates bring together a range of medical professions to offer advice on particular clinical conditions.
Health and wellbeing boards
Public health funding is primarily led by Public Health England and local governments, focusing on public protection through disease prevention and health improvement. Health and wellbeing boards have been developed as main part of this structural change, with the aim of improving care through health and social services. Public Health England and local governments have begun to commission some former enhanced pharmacy services, including smoking cessation, sexual health services and substance misuse services, nationwide. In Norfolk, a community-based physical activity programme with a pharmacy referral scheme is under way. This programme is designed to build on accessibility and expertise of pharmacy, helping and supporting patients to make informed health and well-being choices.
Where do pharmacists fit in?
Neither CCGs nor ATs have a pharmacist-designated post within them. Primary care pharmacists, however, are often based within CCGs or CSUs. Their role ranges from practice-based support to the development of strategies to ensure optimal medicines use, enabling the best outcomes for patients from NHS investment. Within Sunderland’s (and many other) CCG medicines optimisation commissioning team, pharmacists are employed to review current guidance in relation to medicines and liaise with stakeholders such as GP practices, community pharmacy and secondary care to update and implement any changes.
For instance, the pharmacists monitor and review unlicensed prescribing of specials in the local area to ensure that these high-risk and high-cost products are being prescribed appropriately in primary care. Other current initiatives include the development of a joint primary and secondary care formulary, ensuring shared care prescribing arrangements are safe and robust, and working with the practice support pharmacist team to agree and monitor a medicines optimisation work plan for GP practices.
A blueprint for change
These recent NHS reforms present both opportunities and challenges for the pharmacy profession. Most pharmacists are currently employed within the community sector, a role that traditionally has been commissioned for the supply and dispensing of medicines. As such, community pharmacists are not consistently recognised by professional colleagues as “drug experts” and foremost providers of patient care. The recent shift in commissioning structure, focusing on integrated care, is an opportunity for pharmacists to play a key role in improving patient outcomes from medicines — a role that newly registered pharmacists could slip into with ease.
It is estimated that 1.2 million people visit a pharmacy everyday for a health-related reason. This footfall uniquely positions community pharmacists to provide a more accessible, efficient and patient-driven face to the NHS. Pharmacists could play a key role in reducing accident and emergency visits, as well as calls for urgent services. Since pharmacies have a presence on the high street, open late hours, and possess expertise to triage, treat and refer, they are ideal for providing instant access to out-of-hours care.
This is also an opportunity for pharmacists to broaden their scope in the community through minor ailment schemes and public health programmes. The commissioning of these enhanced services is foreseen to shift from pharmaceutical services to standard NHS services. Therefore, it is a great opportunity for pharmacists to broaden their scope in the community.
Pharmacists should lead and provide services such as anticoagulation monitoring, influenza vaccinations, healthy lung screening, sexual health, and insulin monitoring and titration, alongside the current provisions. The shift in service provision would free GP consultation time for more complex patients and, ultimately, a proposed saving of over £812m.
As pharmacists work towards building a case for “added value for money”, the focus should be on outcomes which will be fundamental in strengthening the case for funding acquisition. Pharmacists need to demonstrate competency in care and high quality to enhance their relationships with GPs, and, subsequently, secure funding. Community pharmacists’ support for medicines optimisation should be embedded within local and national disease management guidelines. Improving access to the NHS through such services will mean improving patients’ health by early disease recognition, health promotion and improved medicines-related patient outcomes.
It is an exciting time for the profession because this NHS reform could be a driver for the expansion of pharmacists’ scope within the community and their role within the integrated healthcare team. Community pharmacy must find ways to work effectively with commissioners to help identify and meet local and national health needs, building a case for increased commissioning and service provision. So, essentially, your future role in the profession of pharmacy holds huge possibilities for a diverse and rewarding career.
British Medical Association (2013). The structure of the new NHS http://bma.org.uk (accessed 19 November 2013).
The Bow Group Health Policy Committee (2010). Delivering enhanced pharmacy services in a modern NHS: improving outcomes in public health and long-term conditions http://www.bowgroup.org/sites/bowgroup.uat.pleasetest.co.uk/files/Delivering%2520Enhanced%2520Pharmacy%2520Services%2520%252016%252009%252010%2520FINAL_0.pdf (accessed 19 November 2013).
Department of Health (2013). Guide to the healthcare system in England https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/194002/9421-2900878-TSO-NHS_Guide_to_Healthcare_WEB.PDF (accessed 18 November 2013).
NHS Choices (2013). The NHS in England.
http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx (accessed 16 November 2013).
Pharmacy Voice (2011). Community pharmacy: a blueprint for better health. http://www.pharmacyvoice.com/downloads/PV_Community_brochure_AW_14_02_11.pdf (accessed 20 November 2013).
PSNC (2013). Healthcare’s who’s who. http://psnc.org.uk/the-healthcare-landscape/healthcare-whos-who/ (accessed 18 November 2013).
PSNC (2013). The vision for NHS community pharmacies. http://psnc.org.uk/wp-content/uploads/2013/07/PSNC-Vision-August-2013.pdf (accessed 20 November 2013).
Royal Pharmaceutical Society (2013). Now or never: shaping pharmacy for the future. http://www.rpharms.com/models-of-care/report.asp (accessed 23 November 2013).
Citation: Tomorrow's Pharmacist URI: 11132652
Recommended from Pharmaceutical Press