The Pharmaceutical Journal Vol 264 No 7091 p560
April 8, 2000 Forum

AAH Pharmaceuticals and Vantage convention

Community pharmacy's growing role in NHS reforms

Community pharmacists would have a growing role in the primary care organisations set up as part of the National Health Service reforms, predicted Mr Michael Sobanja, chief officer of the NHS Alliance, which he described as the national association for primary care organisations (PCOs) such as primary care groups (PCGs) and trusts (PCTs) in England, local health groups (LHGs) in Wales and local health care co-operatives (LHCCs) in Scotland. Mr Sobanja assured the convention that community pharmacy would not be left out of the NHS reforms. While most PCGs had so far been slightly inward looking, increasingly they would be working with community pharmacy. Some pharmacists were already pharmaceutical advisers, a growing number were involved in diagnostics, and pharmacies were already the real walk-in centres. He also foresaw pharmacists' involvement in community development. The Government needed to make use of pharmacists as highly paid professionals in a key role.

Mr Sobanja said that the PCO of the future would depend on more integrated generalist teams that would include community pharmacists working alongside general medical practitioners, other community health professionals and social services. Pharmacists would also be involved in community resource and treatment centres, which would be like healthy living centres but also involved in matters such as self-help development, diagnostics services and housing advice.
Giving an overview of the NHS reforms, Mr Sobanja said that the major problem in the NHS was the tension between central control and local discretion. The current Government was more controlling, more centralising and more managerial than any he had seen previously.
A second tension was that between supply and demand. The NHS was unable to meet demand, but Government policies such as the introduction of NHS walk-in centres were leading to increased public demand.

These tensions were heightened by factors such as the ageing of the population, the pressure of technological advances on the NHS, demands for greater consumer choice and a Government that was going even further than Margaret Thatcher had done in controlling professional freedoms. New Labour themes included a dismantled "internal market", a modernised NHS, improved public confidence, national standards, clinical delivery, monitored services and "health, not just health care". But what was this really all about for the Government? It was not just about improving health. It was also about keeping financial control, getting a grip on clinical practice, demedicalising care, breaking power bases, modernising care provision, improving public perception and getting the party re-elected.

Michael Sobanja: PCGs have so far been inward looking

As a result of this Government activity, PCOs were facing - but failing to meet - 75 targets, 111 policies, 54 key issues, 34 health improvement targets and 20 supporting strategies. It was all about accountability, ie, holding the professionals to account.
The roles of the PCO were to improve health, to commission hospital services and to improve primary care. In April, 1999, 481 PCGs had been introduced in England. They covered populations ranging from 46,000 to 257,000, and they were accountable to health authorities, with between one and 12 PCGs per HA. There were significant differences between England's PCGs, Wales's LHGs and Scotland's LHCCs. The situation in Northern Ireland was yet to be resolved, since it depended on the currently suspended Northern Ireland Assembly.
PCGs could operate at any of four levels: (1) advisory groups; (2) HA subcommittees with delegated budgets; (3) primary care group commissioners (trusts); or (4) primary care and community group trusts. A major role for HAs was in managing PCGs' performance,
Holding all this together was the health improvement programme, bringing together the HA, the PCG and non-NHS health partners.
So far, said Mr Sobanja, all he had described was about shuffling the cards in the pack. The real change was in clinical practice. The Government's quality agenda involved setting clear standards (through the National Institute for Clinical Excellence and national service frameworks), ensuring dependable local delivery (through professional self-regulation, clinical governance and lifelong learning) and monitoring standards (through the Commission for Health Improvement, national performance frameworks and national patient and user surveys).
One reason for introducing clinical governance standards was to manage poor performance and reduce adverse events. An adverse event had been defined as "an unintended injury caused by medical management that resulted in measurable disability". But what was the true scale of adverse events? Of every 50,000 hospital inpatients - a typical annual admission rate for a district general hospital - 1,850 suffered adverse events, of whom 48 were permanently disabled and 251 died.
Turning to the Government's information strategy for the NHS, Mr Sobanja said that the intention was to create an electronic health record (EHR) for everyone. The core record would be held in the primary care setting, with subsets or summaries of information added from other record systems, such as hospital, social care and community services. The aim was to have an EHR within primary care that would eventually be universally accessible and would record the health care of individuals throughout their lives. It would be accessible to the patient and would be used to support 24-hour care as well as routine patient care. A record created in this way allowed other developments and uses in the future. Information would be more secure, more useful, more easily shared and transferred and, in anonymised and aggregated form, would be a vital aid to national and local health status analysis.