| The re-election of a Labour government presents the NHS and
the private sector with stability in health policy, built on the concepts
of patient
choice, plurality of service provision and contestability (competition)
through commissioning. There is recognition that traditional service
providers are not the only answer to the choice challenge. The public
health White Paper, “Choosing
health”, will engage the public
in a debate around their personal responsibility for health. And the
widely anticipated White Paper on primary care, due to be published in
the autumn, may go as far as enabling patients — specifically those
with long-term conditions — to determine their own care package;
it is also likely to focus on the need to build a mixed economy in primary
care and increase competition between providers.
Over the past five years, the Government has created a number of drivers
for change. The new contracts in general practice and pharmacy and the
introduction of payment by results facilitate the flow of money from
secondary to primary care. Practice-based commissioning creates incentives
for primary care — most notably GPs — to innovate and redesign
services to minimise referral. Add to that patients exercising real choice
over the care package they receive and it creates a highly complex new
environment for primary care contractors.
How the different players — especially pharmacy and GP contractors — react
to this environment is interesting to explore and may give some indication
of the challenges ahead. This article extrapolates these changes in primary
care to a point where high street-style convenience, consumerism and
competition between providers — not policy — drive service
development.
In this new world, entrepreneurial general practices enter into partnership
with private sector venture capital companies to establish public limited
companies, operating through alternative providers of medical services
(APMS) contracts. Business managers work with high street partners on
joint health promotion campaigns that achieve high brand awareness of “General
Practice Plc” — brand awareness is key when patients choose
where to go for their care since customer loyalty alone ensures stability
of revenue. The drive to maintain brand quality is also the key to service
improvement.
Practices invest significant resources in infrastructure to enable them,
in partnership with consultants, to perform complex procedures in the
community. These specialists become shareholders in the Plc and so benefit
financially from this arrangement. The harder they work to avoid referral
into more complex expensive environments, the more they are rewarded.
In addition, the Plc is a major shareholder in an in-house pharmacy.
The pharmacy is much more than a place to pick up prescriptions. It is
where most monitoring of people with long-term conditions and medicines
management takes place, using new technology to enable point-of-care
testing and diagnosis. The Plc has also constructed a fitness suite as
part of its well being and weight reduction strategy.
In a nearby regeneration area, four pharmacy contractors join forces
and win an APMS contract for provision of primary care medical services,
alongside their pharmacy work. To free time, they share investment in
automated dispensing; the pharmacists train and register as independent
prescribers, and two nurses join the new company “Community Pharmacy
Plc” as partners. Pharmacists manage all minor illness — and
nurses focus on long-term conditions, while working closely to ensure
integration with pharmacists’ medicines management work — most
notably medicines utilisation reviews (MURs) and the management of repeat
medication. The model is proving so successful — and so cost-effective
at addressing the chronic lack of primary care capacity — that
the company is considering franchising the concept to other pharmacy
contractors and primary care trusts. Discussions are ongoing with three
inner city PCTs that are keen to progress the idea.
There has been significant specialisation within pharmacy locally. One
supermarket pharmacy, opened after a successful application under the
100-hour opening exemption, has been commissioned to provide a seven-day
walk-in service, plus a number of additional and essential medical services
at the weekend, using a nurse, supported by the out-of-hours home care
team. Throughout its extended hours, it also has an APMS contract to
run a minor illness service. All these services are fully integrated
with the local out-of-hours network. The success of these services in
reducing unplanned hospital admissions has triggered further investment
in the service.
Another supermarket pharmacy has developed a specialist role in health
promotion. Its in house dietitian, funded by the PCT, works directly
with a local team of health trainers. The dietitian shops with clients
and refers them if necessary to a Sure Start scheme, supported by the
supermarket, that provides cookery lessons and free cooking utensils
to families with young children. Clients can also access the smoking
cessation service provided at the pharmacy.
A number of neighbourhood pharmacies are also working in partnership
with a one-stop centre. Since there was already adequate service provision
in the area, the pharmacies joined together through a consortium to provide
a limited service on site, with the on-site pharmacist working with GP
practices when the pharmacy is closed. The majority of patients choose
to have their repeat prescriptions dispensed closer to home — and
these pharmacies monitor patients’ therapy and provide targeted
MURs and prescription interventions. All the pharmacies are happy to
work closely in partnership with the one-stop centre pharmacist since
they all have a stake in the business — and patients are delighted
with the convenient service on offer. There is talk of investment in
near-patient diagnostics, including automated chemical pathology, ultrasound
and magnetic resonance imaging because an investment company is looking
for commercial partners with potential consulting space in the hope of
winning the locality’s diagnostic screening contract, which is
out to tender.
Surprisingly, all these services co-exist happily alongside each other.
The services patients need are closer to home, and there is so much more
capacity in primary care that everyone is happy. So, when the local hospital
downsizes, there is no public outcry. In fact, the public does not notice
at all.
The only thing we know about the future is that it is difficult to predict,
but all of these scenarios could happen sooner rather than later, given
the current primary care policy context. Pharmacy and general practice
are bound to change in the years to come — but what will the future
look like? Only patients and primary care contractors can decide. But
the result will be modern services that meet the needs of 21st century
people — and primary care as we know it will seem like a sepia
picture from the past.
|
The
Pharmaceutical Journal