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	The Pharmaceutical Journal Vol 267 No 7161 p235-236 18 August 2001	This article Reprint Photocopy
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Pharmacy must be represented when the balance of power is shifted

Dr Hopkin Maddock, a former President of the Royal Pharmaceutical Society, looks at the consequences for community pharmacy of the Department of Health’s recently published consultation document “Shifting the balance of power within the NHS” and argues that pharmacy bodies must express in forceful terms to the Government that pharmacy representation on the new primary care trust executive committees is essential

The document “Shifting the balance of power within the NHS: securing delivery” was published on 30 July. It sets out the organisational changes being made to support the NHS Plan for England. Primary care groups are to be disbanded and primary care trusts developed to fulfil their potential. There will be the creation of fewer, larger and more strategic health authorities.

Strategic health authorities

Strategic health authorities (SHAs) will be new organisations. They will be larger than current HAs, covering an average population of around 1.5 million people, and will be roughly aligned with clinical networks. Although the responsibility for securing local health services will be devolved to PCTs, SHAs will provide strategic leadership. The wider span of control will enable SHAs to consider the overall needs of the health economy across primary, community, secondary and tertiary care, and work with PCTs and NHS trusts to deliver a programme to meet these needs.

The profession must ensure that SHAs have adequate pharmaceutical representation to ensure that pharmacists who are at the hub of patient contact and care are engaged and involved when decisions are made involving community pharmacy services. The new roles and responsibilities of SHAs will become fully operational subject to the passage of the NHS Reform and Decentralisation Bill.

Primary care trusts

Primary care trusts are described as the most local NHS organisation and are to be led by clinicians and local people. Devolving power and responsibility to PCTs lies at the heart of the proposals. PCTs will be the cornerstone of the local NHS. Devolving power and responsibility to PCTs offers real opportunities to engage local communities in the decisions that affect their local health services. This will be one of the key changes facilitated by the new role for PCTs. PCTs will also be expected to ensure that more power is available for frontline staff.

PCTs will be responsible for improving health and securing the provision of services to meet the needs of their local community, building new partnerships with a range of partners, including local authorities, NHS trusts, SHAs, and other PCTs and local communities. The functions of a PCT include:

improving the health of the community, by assessing the health needs of their local community and preparing plans for health improvement which recognise the diversity of local needs.

securing the provision of a full range of services, including primary, community care and secondary care services for their local populations as SHAs step back from a hands-on commissioning role.

taking responsibility for all family health service practitioners, allowing for a coherent view of the development of all NHS services in the area.

taking responsibility for the management, development and integration of all primary care services (medical, dental, pharmaceutical and optical) in the light of the changes set out in the NHS plan, in “Modernising NHS dentistry — implementing the NHS plan” and in “Pharmacy in the future — implementing the NHS plan”.

The principle of devolution means that PCTs should take control of the main revenue allocation, giving them the necessary power to shape the development of local services. This will be achieved by allocating 75 per cent of total NHS funds direct to PCTs to secure the provision of services by 2004. Allocating resources to PCTs will enable resources to be much more closely matched to the needs of the local people.

Pharmaceutical Dimension

The fundamental change in shifting the balance of power in the NHS affecting community pharmacy is the change of responsibilities from health authorities to primary care trusts. In future PCTs will be responsible for:

Maintaining the pharmaceutical list of contractors

Applications to provide NHS pharmaceutical services by pharmacies

Applications to provide NHS pharmaceutical services by GPs

Determination of rurality

Relocation of premises

Remuneration and payment systems

Access to medicines out-of-hours

Services to care homes

Domiciliary oxygen services

Disciplinary procedures

Complaints procedures

Local pharmacy initiatives

In addition PCTs will be responsible for implementing “Pharmacy in the future”, including:

Repeat dispensing arrangements

Pharmacist prescribing arrangements

Electronic prescribing implementation

One stop primary care centres

Medicines management and concordance

Provision of emergency contraception

Continuing professional development

Smoking cessation

Clinical governance

Services for drug misusers

Local pharmaceutical services

The decisions on all the administrative functions and future innovation regarding community pharmacy, set out above, will present major conflicting dilemmas with regard to probity when decisions have to be made regarding commissioning and, separately, surveillance of professional services and resources. All of these functions will be the responsibility of the PCT executive committee which has been set up by direction of the Secretary of State under sections 17 and 126(4) of the NHS Act 1977 and regulation 9(1) to 9(3) of the Primary Care Trusts Regulations 2000 (see below).

Composition of PCT executive committees

The PCT executive committee shall have no more than 15 members. The members shall comprise:

the chief executive and director of finance of the trust

not more than two persons who are employed by a relevant local social services authority

professional members

The professional members shall include:

at least one person with professional qualifications or experience relating to public health or health promotion

a number of medical practitioners, not exceeding seven

a number of nurses, not exceeding seven

The number of professional members shall exceed the number of other members and, in the case of a trust permitted to provide services directly to patients in the exercise of functions conferred on it under section 17A(1) of the 1977 Act, the Executive Committee (a) shall have a majority of members who are not medical practitioners; (b) shall have a majority of members who are not nurses.

The professional members shall be appointed by the chairman and at least two non-officer members of the trust.

There is no statutory provision for a pharmacist on the executive committee, yet pharmacy participation will be essential in debates concerning the wide-ranging pharmaceutical services.

It must be noted that the executive committee structure was promulgated before the projected extended role of PCTs was published. The statutory provision for a pharmacist will be crucial in areas where dispensing doctors play a major role in the provision of health care.

The financial implications of the changes in the new NHS are that PCTs will be allocated 75 per cent of NHS funds, worth in total about £42bn for 2000–01. Pharmaceutical care in the NHS in England, including the costs of medicines, is valued at around £6bn, equivalent to 14.3 per cent of total NHS funds (according to the Pharmaceutical Services Negotiating Committee), thus its administration will account for nearly 19 per cent of PCT expenditure. Of this expenditure, nearly £5bn is funded by pharmacy contractors to cover the costs of NHS medicines. In addition pharmacies sell over-the-counter medicines, which contribute to the community’s well-being, worth some £1.45bn. PCT executive committees, as presently constituted, will have powers to make decisions which will have a major impact upon pharmacy contractors’ financial projections, without any pharmacy representative being present.

The future of local pharmaceutical committees

Local pharmaceutical committees were established and draw their authority from Section 44 of the NHS Act 1977, which states that where the Secretary of State is satisfied that a committee for the locality of a health authority is representative of persons providing pharmaceutical services in a locality, he may recognise the committee as the LPC for the locality concerned.

It is evident, historically, that LPCs have been aligned with health authorities, which were also established by the NHS Act 1977. Under Section 8.1 of the Act health authorities were charged with making arrangements for the provision of general medical services, general dental services, general ophthalmic service and pharmaceutical services.

In 1999, health authorities were also charged with administering arrangements for certain additional pharmaceutical services, which included pharmaceutical advisory services to care homes, additional pharmacist access services and domiciliary oxygen services.

The financial arrangements for the provision of these services were to form part of health authorities’ main expenditure. In future, the new SHAs will not be responsible for community pharmaceutical services. It will, therefore, be logical for LPCs to be aligned with the new PCTs; there will be no need for alignment with the SHAs. The NHS Reform and Decentralisation Bill needs to revise the relationship between existing health authorities and their local advisory committees set out in the NHS Act 1977, so that formal linkages are set up between the new PCTs and local advisory committees.

Changing the LPC structure to match that of the new SHAs will present major logistic difficulties. In the South West, for example, the new boundary would extend about 140 miles from east to west and about 40 miles from north to south, covering no fewer than 250 contractors. The likelihood of a representative LPC with a knowledge of the diverse rural and urban communities, would be extremely small.

As the new PCTs will evolve from existing groups of PCGs which are coterminous with health authorities, it would be logical to retain an LPC with its present boundary. This would aid the Government’s intention to ensure there is no fragmentation of services and that there is consistency of service provision. At present there are 95 health authorities, which will be reduced to 30 SHAs. The number of PCTs is envisaged to increase to around 180, potentially requiring the number of LPCs to be doubled.

LPCs are totally independent of any other organisation. They are autonomous and are recognised in, and bound by, the provisions of the NHS Act and the Regulations. The constitution of an LPC specifically reserves places for independent contractors and company contractors. It also provides for employee membership in order that the views of employees are available to the LPC. The employee members are expected to voice the views of employees working within the locality, regardless of the employer for whom they work.

Disquiet has been voiced by many LPCs over the difficulties incurred in getting independent pharmacy contractors to stand as candidates in LPC elections. However, the PSNC issued an amended model constitution for LPCs in January 2001 to widen the co-option powers for LPCs to fill vacancies. In the South West, if an LPC is not retained with its present boundary the alternatives may well prove to be unworkable. For example, in Cornwall, responsibilities for pharmacy contractual matters will be transferred from the health authority to three PCTs. The most recent two Cornish LPC elections have each resulted in at least four vacancies on the LPC. There are 86 pharmacy contractors, of which only 15 are under single ownership; 10 of these are unlikely to be interested in participating in an LPC. To form three LPCs with a balanced membership from relatively small numbers of contractors would present difficulties.

The present LPC with its diverse representation of the different sectors of community pharmacy, has shown itself able to represent the interests of all Cornish contractors. The LPC’s constitution may however, need to be remodelled to include the obligatory attendance of PCT “support pharmacists” as observers, since links between the LPC and PCT will be of paramount importance. In addition task groups could be appointed by the LPC to cover each PCT in its area.

Conclusions

Full implementation of the proposals to shift the balance of power in the NHS will require primary legislation. Changes to primary legislation are required to enable resources to be allocated directly to PCTs rather than to health authorities as at present, and to enable PCTs to engage in the management of pharmaceutical, dental and ophthalmic contractors. The NHS Reform and Decentralisation Bill announced in the Queen’s speech will provide the vehicle for the necessary changes to be made.

Although “Shifting the balance of power” was only published on July 30, comments are required by September 7. It is essential that all national pharmaceutical bodies conform to this timetable. They must express in forceful terms that amendments be made, if necessary, to the NHS Reform and Decentralisation Bill to embrace the needs of the pharmaceutical profession in its pursuit of the provision of excellence in the pharmaceutical services provided to patients.

In particular the leaders of the profession must persuade the Secretary of State to amend the Primary Care Trust Executive Committees (Membership) Directions 2000 to include pharmacists. Statutory provision for pharmacist representation will be crucial in areas where dispensing doctors play a major role in the provision of health care.

The NHS Reform and Decentralisation Bill needs to revise the relationship between existing health authorities and their local advisory committees set out in the NHS Act 1977 so that formal linkages are set up between these committees and the new PCTs.

Where acceptable to the local pharmacy contractor community, the current geographical pattern of an LPC should be retained. The model constitution of an LPC should be revised to include the obligatory attendance of each PCT “support pharmacist” in its area. Where appropriate, task groups should be appointed by the LPC to liaise with each PCT.