A wheel is a pretty efficient tool. It is round and has an axle in the centre, which must be kept well lubricated for efficient operation. Of course, you can make it larger or smaller, thicker or thinner - and you can shave bits off or put bits on to get batter balance. But a wheel is a wheel. The National Health Service is like a series of inter-related wheels, so that, if you mess about with one bit, then it has a knock-on effect on something else.
The Government's NHS plan for England, launched on July 27, has been much vaunted as the biggest shake up of the service since 1948. I have yet to see what is so radical about it. Indeed, is anything actually new about it?
The time given for public consultation was very short. If anything of major significance had come out of the consultation, then the Government had no time to incorporate it into their thinking. In fact, the public feedback is a regurgitation of already announced health strategies by the present and former governments.
Twenty-seven per cent of respondents wanted to see more NHS staff - more doctors, nurses, scientists and therapists, deserving better pay and doing less paperwork. Ninety per cent were satisfied with the performance of doctors and 96 per cent with the way that nurses did their jobs.
Most respondents thought that waiting lists were too long, that waiting in accident and emergency departments was too long and that waiting on trolleys was unacceptable. Almost a third wanted to see GPs extend their opening hours.
The public is said to support the return of a "modern matron", able to make decisions and implement them. The wish forbetter facilities and local services, reduced local variation in access, and reduction in clerical work were strongly featured.
There were a few throw-away comments, with no indication of whether they were representative of a major body of expressed opinion. One complaint was patients having to wait far too long for discharge medication, which we all accept is a problem, but not always within pharmacy's power to resolve.
An obvious, if long-term, opportunity for the pharmacy profession is through the expressed Government wish to develop new ways of working and reduce old fashioned demarcation between staff. The Royal Pharmaceutical Society's Council, staff and members have done an excellent job in promoting the skills of pharmacy to the Department of Health. Now comes the crunch about what the Government is prepared to do about it, and what we can progress with other professions.
The Government proposes to develop 500 "one-stop primary care centres" by 2004, bringing together primary and community care services and including GPs, pharmacists and others contractor professionals. This sounds like a return to the 1970s philosophy of health centres, but in an updated form.
From my experience, health centres deserved greater success than many achieved. GPs were attracted in, but many later found that it was to their financial advantage under the "cost rent scheme" to leave and set up their own facilities. This was often to the detriment of patient access.
Whereas some developments were actively supported by community pharmacists, overall there was reluctance to participate, combined with the fact that some health authorities saw pharmacy premises as opportunities for income generation rather than for improved and integrated patient service. Perhaps this time there will be a greater incentive to attract a pharmacy presence, and, make no mistake, close pharmacy involvement is essential if we want to be part of the primary care team and benefit from integrated working.
I appreciate that, like GPs, pharmacy is reluctant to consider becoming part of a salaried service with perceived loss of independence. I suggest that we need to look at options with an open mind, perhaps recognising that there is a professional element that could be salaried, matched to a medicines sale role that could be contracted or perhaps franchised.
There should be 5,000 extra "intermediate care beds" by 2004, either based in community or cottage hospitals, in designated wards in acute hospitals or redesignated private nursing homes. Some will be newly built.
The principle is eminently sensible, with many acute hospital beds now occupied by patients who certainly do not need the full range of high-tech, on-site support available. From a pharmacy point of view, many such patients should be able to self-medicate with varying degrees of supervision, allowing greater patient involvement, better concordance and reduced nurse input to routine procedures.
The big question is how pharmaceutical services are best provided to these new beds.
For a community hospital, whether GP run or serviced by hospital-based medical staff, a service provided by community pharmacy is certainly a viable option, perhaps offering more prompt supply and better liaison with primary care services. But, I suggest, it must be more than supply only - a full medicines management and pharmaceutical care package should be the norm for service specification in the best interests of quality and of economy. Of course, if a hospital-based service can come up with better service and more economic delivery, then it must be given the opportunity. In either case, it could be salaried or franchised.
I am not sure whether the idea of a modern matron came out of the public consultation; neither am I happy with the idea of a new Hattie Jacques style of authoritarian nurses. However, I have no doubt that better management of resources at ward level could reduce patient stay and improve bed occupancy. Those who have been a hospital inpatient will appreciate just how long is spent waiting for something to happen, whether it be waiting for laboratory test results, waiting for someone to act on them, or waiting for medicines to arrive before the patient can go home and the bed be released.
It is all a question of getting the logistics right - deciding where we need to be by when, and what needs to be done to get there. Pharmacy clearly does have the skill to input to efficiency improvement, both within its own resources and also in defining what is necessary from others to improve its service - whether by defining when the prescription needs to be written, how it is communicated to the pharmacy and how the patient will receive the medicines and any necessary advice.
The NHS plan provides an opportunity to break the mould in many ways, although I have yet to be convinced that it justifies its billing as the biggest shakeup for the NHS since 1948. Perhaps we shall soon see review of functions and an acceleration of the merging of trusts, of health authorities and of NHS regional offices to justify that billing. There will always be a temptation by any Government to reduce the numbers of "men in grey suits" and to use the money for more caring doctors and nurses, whatever the reality of the situation.
Tony Furber is an independent pharmaceutical consultant in Sheffield and a former regional pharmaceutical officer for Trent