Articles

Modernising the NHS

A pharmacist on the board

By Mary Snell MRPharmS

The 31 members of the National Modernisation Board appointed to oversee the implementation of the NHS Plan for England include pharmacist Beth Taylor. She spoke to Mary Snell, for The Pharmaceutical Journal, on February 9, the day after the board’s third meeting, about the new opportunities for pharmacy that are becoming more apparent as implementation of the plan takes shape

You were appointed last October as the only pharmacist on the NHS Modernisation Board for England. Why do you think that you, particularly, were chosen, and can you explain exactly what this appointment entails? I am very proud to have been asked to take on this role, which may have come about because I’ve been fortunate to have been involved in a number of innovative developments, including NHS Direct, the supply of emergency hormonal contraception by community pharmacists, and collaborative work between community health services and social care. But I see my role on this new body as providing an opportunity to contribute to the implementation of the plan as a whole. It must be good news for the profession that a pharmacist has been included among those "at the top table", to use Lord Hunt's phrase. On a more personal note, as I have spent all my career working for the National Health Service, I feel a strong sense of identity with it and I am delighted to be involved in this way with the modernisation programme. The 31 members of the board are drawn from three groups; patient representatives and carers, leaders of national organisations, and people working in the NHS. I am one of the latter, alongside five chief executives of NHS organisations, a general medical practitioner, a therapist, a nurse, a medical director, a dentist and a professor of surgery. Our input into the board is not to rewrite the plan; it is to inform the implementation process. Members of the board are expected to develop communication within their "natural community" and to speak with them about the plan and its implementation. I have interpreted my "natural community" to mean pharmacy in the broad sense as well as my local health economy in Lambeth, Southwark and Lewisham. Developing an effective dialogue with pharmacists will be very important to all of us on boards and taskforces.

How many other people from the world of pharmacy are involved in the national board and taskforces? Professor Alison Blenkinsopp (professor of the practice of pharmacy at Keele university), the Royal Pharmaceutical Society's public affairs director Beverley Parkin, and I are on the national taskforces for access, communications and older people, respectively. However, similar groups are being appointed at regional and local level and quite a number of pharmacists are being appointed to those, including Dr Stephen Chapman (regional pharmaceutical adviser, West Midlands), Wendy Harris (community pharmacy adviser, North Derbyshire health authority) and Dr Gill Hawksworth (community pharmacist and member of the Society’s Council). About half of the regional modernisation boards already set up include a pharmacist. But even where there is not a specific pharmacy appointment, we can still develop useful links by keeping in contact with others who are appointed. For instance, we are all concerned about pharmacy workforce issues, and I would encourage people to make contact with workforce taskforce members at all levels. The NHS plan suggests that the national structure of a modernisation board and taskforces is expected to be mirrored at regional and local level, and this is happening now. There may, however, be some variation at local level, and pharmacists will need to check the detail with their local health authorities. I hope that the new local modernisation groups, as they are drawn from a wider membership than current local groups, will offer us a better opportunity to work alongside colleagues and patients on the implementation of the plan. There is certainly a real feeling at the national board that we want to "do things differently". Is the modernisation board also involved in the pharmacy strategy? The pharmacy strategy is a development from the NHS plan; it is not a separate piece of work. It just expands on the specific medicines and pharmacy elements within the overall NHS plan. It is a difficult task to see how these two documents fit together. How do we keep them both in our sights? Being realistic, we hope that the majority of pharmacists will read the pharmacy strategy but perhaps not everyone will read the whole plan. I expect that pharmacy organisations will be preparing briefings for their members which will describe more clearly how the two documents link together, and also explain the timetable for the implementation process. The NHS Implementation guide, which was published in December, is on the Department of Health website. It sets out the milestones and targets for the coming financial year, and there is also a lot of planning work going on in the NHS, looking further ahead. The pharmacy strategy is a challenging programme which I believe pharmacists have cautiously welcomed. It clearly reflects the underlying themes of the plan in that it is patient-focused, envisages pharmacy working in a more integrated way with the NHS, and contains some ambitious targets. Although it is helpful for pharmacy and medicines-related developments to be highlighted, the strategy has to be seen in context, as part of the overall NHS plan implementation programme. We must be careful not to lose sight of some wider developments such as care trusts (primary care trusts that include social services), Care Direct (the equivalent of NHS Direct for social care, and future national service frameworks, which will all have an impact on our work. What opportunities are there for feedback from pharmacists to be heard at the board? The board has met three times and we have already seen examples of how comments and discussion have been picked up and fed into the NHS Executive. For example, at the second meeting, in December, there was discussion about the need for NHS staff to have sufficient "headroom" (meaning time out, or thinking space) in order to figure out how to respond to the plan. That was recognised and was referred to a few weeks later in Nigel Crisp's [NHS chief executive] introduction to the implementation plan. I feel that Ministers are committed to making the board and taskforces work well and they are clearly listening closely to the discussions taking place. For example, Alan Milburn [Secretary of State for Health] asked us at the first meeting, last October, if we could each provide one page of personal feedback before future meetings on how things were progressing locally and what we had been doing and hearing from colleagues. Although daunting at first, this feedback at subsequent board meetings is both fascinating and of real value. I know that it is read by Ministers, and is an accurate "reality check" from NHS staff and users, not just a rosy picture. I have made reference in my feedback to the strong feeling in the profession that it will be difficult to implement some developments unless we address the current problems of recruitment and skill mix within the pharmacy workforce, and I have also highlighted queries about the sequencing of pharmacy developments. Where is the money going to come from? There is some targeted money identified in the pharmacy plan (eg, for medicines management) but let’s not forget that there will also be some new money coming into the system for a whole range of developments in the NHS plan itself. We need to watch out for areas such as the national service framework for older people, and improving access to services, where there are likely to be medicines-related developments that pharmacists can contribute to. We also need to bear in mind that this modernisation programme is not just about new things happening, it is about reviewing our existing resources together with new ones, and thinking about how things could be done differently for best effect. We are being encouraged to look at how all our clinical services are run, and to ask if there is a cleverer way — using people’s skills, technology and communications — of improving it. For the innovators in pharmacy, I don’t think we are likely to have a better opportunity to think quite radically. If we can come up with ideas for pharmacy developments that are clearly going to benefit patients, the modernisation groups will want to hear about them. My personal view is that proposals developed by pharmacists in partnership with others are the most likely to be successful.

NHS plan In July, 2000, the Government published “The NHS plan: a plan for investment, a plan for reform” (see www.doh.gov.uk/nhsplan/default.htm), its vision of the National Health Service for England. The NHS plan sets out the Government’s development programme for the next 10 years. The Government sees the plan as a "once in a lifetime opportunity to bring about the most fundamental and far-reaching reforms the NHS has seen since it was created". Its vision is "a health and care system focused on the service user, not around those delivering the services". As part of the implementation programme for the NHS plan (see www.doh.gov.uk/nhsplanimpprogramme/index.htm), some new structures have been set up. These include a national modernisation board and 12 taskforces.

What is the timescale for implementing the plan? The timescale for the plan in the short term is set out in the implementation guide. In terms of pharmacy developments then maybe the first will be the medicines management programme which is just beginning now, and then the rollout of NHS Direct's referral to community pharmacists which should be complete by April, 2002. Some major developments will require changes to the law and we are very pleased that these changes have been included in the Health and Social Care Bill currently going through parliament. There are clauses that cover the extension of prescribing to new groups of practitioners and the Bill also proposes the necessary changes to allow local pharmaceutical services pilots to go ahead. Nurse prescribing is a good example of something which is a major opportunity, not a threat, for pharmacists, although not all may see that initially. What we have learned so far is that: There will be many more prescribers who are eager to receive help and support in carrying out this new role. Some may lack confidence, so will rely on the knowledge and support available from pharmacists The links between nurses and pharmacists have been strengthened as a better understanding of each other's role develops A mutually supportive relationship between nurses and pharmacists is the best foundation we could have as we move towards pharmacist prescribing — we alienate other prescribers at our peril Extending prescribing to new groups or practitioners should engage all pharmacists — in community practice, in health authorities, in primary care groups and in NHS trusts.

Modernisation board A national modernisation board has been set up to help drive forward the plan and help hold the NHS to account. The board is composed of 31 health professionals from three groups: national organisations; patients and citizens groups; and people working in the NHS. The board is chaired by the Secretary of State for Health, and the Chief Executive of the NHS is an ex officio member. The purpose of the Modernisation Board is to advise the Secretary of State for Health. It has three main functions: To help oversee the implementation of the plan To facilitate a dialogue between the Department of Health, people working in the NHS and patients To produce an independent annual report on the progress of the plan

What is the Modernisation Agency? The Modernisation Agency is a new body which has been set up specifically to help local clinicians and managers redesign services in line with the plan, and the medicines management action team will be linked to it. So while the Modernisation Board, not unlike the board of a company, will advise, give feedback and generally steer the implementation process, the agency is the executive arm which aims to ensure that it is put into action. The Modernisation Agency includes some new "change agents" that pharmacists may be unfamiliar with, for example, the National Patient Access Team (NPAT), the Primary Care Collaborative, the clinical governance support team, cancer collaboratives and a leadership centre. There have been some very successful initiatives so far and pharmacists could learn a lot by studying these. What about Scotland and Wales? Although Scotland and Wales have their own plans, many of the themes will be consistent. The chairman of the Society’s Scottish Executive, Alison Strath, is a member of the modernisation board in Scotland. The plan for Wales has only just been published, so there have been no announcements about board members yet. What happens if Labour is not returned at the next general election? This is a big programme. My view is that even if there was a change of government, the plan could change focus but it is not likely to stop. What will implementation of the NHS plan and the strategy mean for day-to-day pharmacy practice? And does the plan apply to all areas of practice? This isn't a strategy for just one sector of the profession. It will involve every pharmacist, no matter what branch they practise in, because we are all involved with the NHS in one way or another. Some people have said to me that they find the pharmacy strategy has a lot to offer community pharmacy, but less for those in hospital practice. I don’t think this is true, but maybe the strategy just reflects the overall theme of the "Pharmacy in a new age" initiative, where many community pharmacists voiced the need for significant changes. Coming back to your role on the national board, and the speed with which things are moving, what do you need from the profession and how do you propose to communicate with pharmacists — both to keep them informed and to gather useful feedback for the board? This is really quite a challenge! I do feel strongly that I can only be effective as a member of the modernisation board if I have good support and communication with practising pharmacists. Alison, Beverley and I have given some thought to this and we are taking it forward in two ways: First, with the support of the main pharmacy bodies, we have convened a two-monthly briefing meeting. This aims to develop two-way feedback on progress with implementation, and we recently met for the first time. There was a lot of support from pharmacy organisations to meet together in this way, which I am delighted about as I believe we are much more likely to be influential if we can adopt a pan-pharmacy approach where appropriate. Secondly, the discussions we have already had within pharmacy have made us realise that many pharmacists find it hard to access the information that they need to respond to the plan, and the information that is available may only relate to one sector of the profession. So we have proposed a website devoted to the NHS plan and its implementation, and we are pleased that the Society has agreed to host it. The pharmacy organisations at the briefing meeting agreed to work with us on this, and it will include links to their sites. In developing this resource, we are trying to anticipate the needs of all pharmacists who want to work with this agenda, whether they are on local pharmaceutical committees, in community pharmacy, in trusts or in health authorities. What will distinguish this website from other resources is that it will be structured throughout to reflect the structures of the modernisation programme, ie, the taskforces, because we believe that this will be most helpful for practitioners as they get involved in local work. For example, NHS Direct and out-of-hours services will be grouped under the heading of the access taskforce, because this is how they may arise on local agendas. The website will give background information eg, NHSE policy or strategies; related pharmacy resources and developments; and examples of good practice. We hope to launch it at the beginning of April.

Taskforces Twelve national taskforces have been set up to take forward specific areas of the NHS plan. They will plan implementation, support change and monitor and adapt plans. The taskforces will play a key role in highlighting and spreading good practice across the whole of the health and social care service. They are made up of over 140 people drawn from the service, patient groups and other key national and local organisations, working alongside staff from the Department of Health. A member of the modernisation board serves on each taskforce. All these taskforces will be mirrored at regional and health authority levels. The taskforces cover coronary heart disease, cancer, public health and inequalities, people with mental health problems, older people, children, workforce, quality, access, capital and capacity, performance management, and communications.

Can you tell us about the work of the older people taskforce? The older people taskforce has an enormous work programme. It includes not only the NSF for older people but also development of intermediate care services, care trusts, Care Direct, "winter pressures" and long term care funding, among others. Many people have been uncertain what the term intermediate care covers. A health circular (HSC2001/001) has recently been published which aims to support expansion of these services. You have used the term "doing things differently". Can you explain what this means? The new guidance for intermediate care that I just mentioned is an example of doing things differently. The guidance covers a wide range of potential service models such as rehabilitation units, community hospitals, hospital at home, rapid response teams, and enhanced domiciliary care. However, it only identifies a common aim — of time-limited intervention — and there may be a number of models for achieving the aim. This is a challenge for pharmacy because we are used to identifying models of good practice by the practice setting, not by the client group. So in this case we need to identify models of good practice that meet the aims of intermediate care regardless of the setting. This is an opportunity to look at models of good practice across all sectors of the profession. In fact the whole programme is a big opportunity for people to put forward existing and new models of good practice and to share them as widely as possible across the profession and beyond it. It is likely that, as is often the case, it is the innovators in pharmacy who may be particularly influential in taking forward some of this work. Could pharmacy learn anything from looking at how other professional services have been modernised? Yes, definitely. Interesting and successful models for new ways of working have been developed through personal medical services pilots in primary care, and the Primary Care Collaborative is another example of innovative ways of changing practice. Medicines management work plans to use these techniques. We need to be looking at these carefully and considering how to we can import similar learning methods into pharmacy practice Can you say something about the involvement of social services in the NHS plan? As you can see from the summary chart of the organisational structure [p256], social services will be influential at both regional and local level. There will be strong links with social care, and sometimes more widely than that, for example with housing and leisure services and with benefits.

Pharmacy strategy In September, 2000, the Government published "Pharmacy in the future — implementing the NHS plan" (see www.doh.gov.uk/pharmacyfuture/index.htm), its vision of the role of pharmacy in the new NHS for England. The government’s strategy for pharmacy indicates its vision for the profession over the next five years. The programme is patient-focused, and it identifies pharmacy and medicines-related developments for the profession as well as for others in the NHS. The four main areas of change in "Pharmacy in the Future" are: better access to services, getting the best from medicines, redesigning services and getting the most from staff. Many of the elements of the pharmacy programme map on to the five key areas of pharmacy activity that the "Pharmacy in a new age" strategy was based on, ie, the use of prescribed medicines, the management of long term conditions, the management of minor illness, advice and support for other health professionals, and maintaining good health and preventing illness.

What do you suggest that pharmacists do now? Read the pharmacy strategy and ask: "Do I want to be part of this?" Think about what the consequences might be if you don't get involved. Make sure you know how things are unfolding. Talk to pharmacy colleagues locally, and to others about what is going on. Use and develop the networks within pharmacy, including any new ones such as pharmacy development groups. We absolutely must be properly linked in at local level to the NHS. I am aware that people who contract with the NHS as opposed to being employed by it can often miss out on some of the publications relating to the NHS plan, and I have already drawn attention to this at the board. Board and taskforce members at all levels will need to hear from pharmacy practitioners and we would encourage them to do this via e-mail: to me at Beth.Taylor@chsltr.sthames.nhs.uk or taylortbeth@cs.com, to Alison at a.blenkinsopp@mema.keele.ac.uk or to Beverley at bparkin@rpsgb.org.uk. Is pharmacy finally going to leave behind the many "crossroads" we always seem to be at? Or is this just another "initiative"? This is definitely not just another initiative. It is the 10-year plan, and it is likely to lead to the biggest changes in the way NHS services are delivered since the start of the health service. Do you really think this vision can be realised? It is clear to those of us on the board and taskforces that they have the feel of a fresh approach and are more inclusive than other committees we may have been involved with in the past. I believe we are hearing a more innovative and radical kind of discussion and feedback than before, perhaps as a result of the unique makeup of these boards and taskforces in bringing together a wider group of people with a clear common aim. I am optimistic that in five years' time the "crossroads" will be way behind us and we will be several miles down the right road, preferably enjoying the company of other health professionals.

Mary Snell is a pharmaceutical journalist and editor of the Royal Pharmaceutical Society’s website

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