A community pharmacy session on September 14 heard presentations on National Health Service developments. Ms Marion Dinwoodie (director, community services and primary care development, Gateshead and South Tyneside health authority) described developments surrounding primary care groups, Ms Georgina Craig (head of professional development, National Pharmaceutical Association) outlined opportunities for community pharmacy in the new NHS, and Mr Phil Parry (chairman, Welsh Central Pharmaceutical Committee) and Mr Chris Martin (board member, Pembrokeshire local health group) described developments in Wales
Describing the development of primary care groups, Ms Marion Dinwoodie (director, community services and primary care development, Gateshead and South Tyneside health authority) told the Conference that the Government White Paper, "The new NHS: modern, dependable", had paved the way for their foundation. Their core functions were to improve the health of the community, to develop primary and community care services and to commission secondary care services.
In her health authority, the past year had seen an enormous effort expended by all parties to bring the new PCG organisations into being. There had been new relationsips to form and new skills to learn. But all health authorities were adapting to the changes and examining their new role in overseeing PCGs.
A role of the PCG was to participate in the development of health improvement programmes (HImPs) and to act on HImP priority decisions. Ms Dinwoodie also mentioned health action zones. These were part of a Government initiative to provide additional targeted support to areas of greatest deprivation. In Tyne and Wear, HAZ co-ordinators were working constantly to assist the channeling of resources into projects which lent support at local level to the health authorities' strategic priorities (including health promotion among the young, the elderly, and people with mental health problems, ischaemic heart disease and cancer).
Building relationships
Much of the early efforts of the new PCGs had been about building relationships and developing communications networks and strategies to allow the public, service users and all stakeholders an opportunity to influence the PCG boards in their decision making, Ms Dinwoodie said. However, bridge building with other primary care professions, notably pharmacists, had often been patchy, and pharmacists should seek to build these relationships prudently.
She advised the conference: "Be proactive by demonstrating worth within the PCG agenda and by working with PCG board chairmen and chief executives on what feels like a comfortable relationship. Do not begin by demanding recognition as a profession."
Ms Dinwoodie said that while PCGs recognised the desire to involve all professions, inevitably, in the first year, they had concentrated on planning around general medical services, prescribing and elements of community service provision. Very high on the PCG agenda was good prescribing practice.
Turning to the concept of clinical governance, Ms Dinwoodie said that it was an integral part of the culture of improvement and performance management. Inevitably, there would be tensions and discomfort around performance management relationships, but more would be achieved by a voluntary sharing of information among independent practitioners in an open, non-threatening environment for discussion. The emphasis had to be on general inprovement of performance and not on a counter-productive, bureaucratic "witch-hunt" to catch poor performers. Clinical governance had to be acceptable to practitioners, who needed to feel that it would make a difference to them and would be "owned" by them. This would be best achieved by the professions persuading themselves of the relative merits of clinical governance, Ms Dinwoodie said. Its success would depend largely on opinion leaders at local level.
Challenge
Ms Dinwoodie went on to talk about membership of PCG boards. Membership had had been prescriptive, owing to the targeted aims of engaging general practitioners, improving nurse integration and improving health and social care partnerships.
"Other professions, such as pharmacy, have felt marginalised, but this need not be so. The real issue is to create relationships fit for purpose and never more than now have good prescribing and pharmacy pratice been central to the agenda. It is up to the profession to take up this challenge," she said.
Opportunities for pharmacy within the new National health Service were huge, Ms Georgina Craig (head of professional development, National Pharmaceutical Association) told the Conference. There were opportunities in five key areas: the management of long-term conditions, the management of prescribed medicines, the management of common ailments, the promotion and support of healthy lifestyles, and the provision of advice and support for other health professionals.
But given the importance of primary care groups in the new NHS, the profession's first priority had to be to get community pharmacists co-opted to PCG boards. Without that, it would be difficult for pharmacists to harness the opportunities.
Ms Criag said that there were three challenges to achieving pharmacist representation on PCG boards. The first was persuading a PCG board to co-opt a pharmacist in the first place. The second was to get funding for co-opted pharmacists to attend PCG board meetings. The third was to ensure that co-opted pharmacists had the resources they needed to make a significant contribution.
Ms Craig told the Conference that the national bodies had been working together on these issues and had had some success. For instance, the NHS Executive had agreed that health authorities or PCGs should meet the locum fees of co-opted pharmacists, and senior civil servants had agreed to follow up individual cases where this support was not forthcoming. The NPA, in partnership with others, had produced a pack to support community pharmacists arguing for co-option and was also looking at what support pharmacists on boards needed.
"However," Ms Craig warned, "all the efforts at national level will be fruitless if community pharmacists do not proactively make the case to PCGs at local level. This is a top priority for the NPA and we are currently working with LPCs which are keen to seek co-option to PCG boards."
Returning to the key areas of opportunity she mentioned earlier, Ms Craig outlined how pharmacists could become involved in the management of prescribed medicines and gave her views on pharmacist prescribing. She said that doctors were responsible for clinical review of patients but did not have time to do it. But community pharmacists saw such patients on a monthly basis so the opportunity for delegation existed. Indeed, there was a strong case for delegation on quality and clinical governance grounds, both of which were cornerstones of the new NHS.
"Clinical governance is about making sure an appropriate professional provides care in order to minimise risk and maximise quality," Ms Craig said.
Logical step
In terms of that argument it was hard to justify the current system and pharmacists should be providing repeat dispensing services and clinical review. Dependent prescribing by pharmacists was the next logical step.
"Once you are responsible for setting review dates and undertaking medication reviews, it is a relatively small step to change doses or drugs within a therapeutic class and agreed protocols," said Ms Craig.
She believed it was conceivable that pharmacist prescribing pilot studies would be running within a few years, and told the Conference that the NPA was planning to work with LPCs within health action zones to look at how such pilots might be developed, especially in areas where GP services were limited and the need for dependent prescribing was greater.
Another opportunity for community pharmacists was prescribing support. Pharmacists were "worth their weight in gold" when it came to managing the prescribing budget, and that well-established role would continue to flourish in the new NHS. Pharmacists would see the emergence of new prescribers, and had an opportunity to support them through local training initiatives.
There were plenty opportunities to go round, Ms Craig concluded, and pharmacy had an excellent chance of rising to them.
Mr Phil Parry (chairman, Welsh Central Pharmaceutical Committee [WCPC]) and Mr Chris Martin (Pembrokeshire local health group) described developments in Wales. The Conference heard that devolution had left its mark not only through the establishment of the National Assembly for Wales, but also in the set up of primary care groups, or local health groups, as they were called in Wales. The WCPC was the body which represented community pharmacy contractors and LPCs in Wales on NHS matters. It was made up of 11 members, two representatives of the five Welsh LPCs and the Pharmaceutical Services Negotiating Committee member for Wales (Mr Parry).
Had the National Health Service Executive "got it wrong" in England, was the question both speakers addressed during their presentation. While in England pharmacists were still fighting for a place on PCG boards, in Wales this was the rule rather than the exception. Mr Parry was "delighted" to be able to report to the Conference that, in Wales, there were two pharmacist local health group chairmen and one vice-chairman. On top of this, many LHG pharmacists chaired prescribing subcommittees. So perhaps the NHSE had got it wrong in England.
Variations
Mr Parry explained that the White Paper introduced by the Welsh Office had been similar in overview to the one in England, but with significant variations. It had suggested the formation of 22 LHGs as subcommittees of the five Welsh health authorities. The LHGs were to have the same function as their PCG counterparts in England, but the LHG structure had not been explicitly set out in the White Paper.
The aim, said Mr Parry, was to get "pharmacists as far into the structure as possible. If there was a board we wanted pharmacists on it. If there was a powerful executive, we wanted to be on that too."
The road to success had seen a lot of discussions and meetings with the Welsh Office, promoting community pharmacists as primary care focused, business orientated, and knowledgeable of patients needs. Most importantly, in Mr Parry's opinion, was demonstrating enthusiasm for involvement.
"The Welsh Office was impressed with our desire to be involved and went to some length to include community pharmacists on LHG boards. Our enthusiasm was not always matched by other professions," he said.
The result had been that the WCPC had been drawn in to help frame the final structure. The LHG board was made up of 11 primary care practitioners (six GPs, two nurses, a dentist, an optometrist, and a pharmacist) and seven other members. The board then elected members of the five strong executive and its chairman, usually a GP. If the chairman was a pharmacist, he or she became an additional, sixth member of the executive.
Problem
One problem that Mr Parry saw with regard to English PCGs was the pressure to move to trust status too quickly. "There is no pressure from the Welsh Assembly as yet. So we are seeing a more limited approach here, with LHGs seeking control of some budgets but not going for the total purchasing," he said.
Mr Parry added that the LHG pharmacists were full board members participating in the full range of board discussions and activities. The WCPC had organised an LHG pharmacist training day in March and a second one was planned for October. The WCPC was also encouraging LHG pharmacists to meet with LPC secretaries and Welsh Assembly members.
Mr Martin provided a more detailed look at what a pharmacist LHG board member actually did.
"My main concern from the start was that the LHG had to be more than just another talking shop. . . . It had to be a body with teeth," he said.
Since LHGs had gone live in April, 1999, the main areas of work at Pembrokeshire LHG had been the development of a performance agreement for 1999-2000, and subcommittees in prescribing, primary care, clinical governance, GP commissioning and information technology had been established to facilitate this. Mr Martin himself was a member of four of those subgroups.
Pharmacy issues
Mr Martin was "particularly delighted" about eight pharmacy related issues being included in the Pembrokeshire LHG's primary care development plan:
"Do you remember the old days when we would be searching the health authority document to see whether pharmacy was mentioned?" Mr Martin asked the audience. At least in Wales it seemed that times were changing.
Mr Martin concluded by saying that while it had been a busy time it had also been an exciting one.
"In saying we must be involved in future developments for community pharmacy, we also must be prepared to invest our time and deliver results," he said.