The Pharmaceutical Journal
Vol 275 No 7356 p30-31
2 July 2005

Society summary

Devolution: why do we need national boards?

The Royal Pharmaceutical Society is currently seeking the views of members on a proposal to reconstitute the Scottish and Welsh executives as national boards and to create a national board for England (PJ, 4 June, p687).The closing date for responses is 18 July. We set out here the views of the three members of the new Council who were elected to the seats reserved for each of the home countries

Why an English board?
The campaign for the proposed regional assembly for the North East of England last year was doomed after its opponents adopted a white elephant as their symbol. Members might be concerned that the same tag could be attached to an English national board for the Royal Pharmaceutical Society — but would this necessarily be so?

Devolution in Scotland and Wales has made the roles of the Society’s Scottish and Welsh Executives clearer, and their reincarnation as national boards follows from this. But with no apparent corresponding devolution in England, what is the role for the English board?

In fact, devolution, especially of health policy, is gradually forcing the Department of Health in London to recognise that although it still has some UK-wide issues to deal with (principally those relating to medicines licensing and the Medicines Act 1968), most of its day-to-day work deals with England alone. Similarly, the Society staff at Lambeth need to clarify which parts of their work are regulatory, and thus mainly British in scope, and which are professional or policy, and thus likely to reflect devolved political priorities in the home countries. Put plainly, the DoH must add “for England” to its title and the Society needs to be careful about what is actually “of Great Britain”. This would reflect the gradual recognition of a separate English sense of national identity, currently manifested in the appearance of the St George’s Cross at major sporting events and on 23 April.

One of the biggest benefits to the Society and its members that might follow from the establishment of an English board is a full-scale review of the Council committee structure. At present, the Practice Committee deals with “policy implementation relating to the practice of pharmacy in its various branches”. This work is likely to be taken over by the national boards and the various specialty groups. Abolishing the Practice Committee would mean that any subsequent review would not simply be able to come up with something that had different names for what was in essence the same old structure. This would lead to a wider, and in my opinion, long-overdue review of the way the Society, the Council and the wider structures work. Concordats setting out which bodies will deal with which issues and how they will co-operate will be a vital part of any new structure. These agreements must cover all parts of the Society.

Another possible benefit of an English board is that it would give a greater structure and focus to the work of the branches in England, the Channel Islands and the Isle of Man. The branches could be involved in policy review, possibly through a policy forum or conference.

Looking much further ahead, having a structure consisting of a Council plus separate national boards gives the Society flexibility to cope with English devolution, should it finally arrive, or the incorporation of members from overseas. It would also allow a way of dealing with the not-quite-unthinkable scenario of having different political parties in power on different sides of the border.

Most of the activities that might fall under the wing of an English national board are already being carried out by the Council, its committees or by existing staff at Lambeth. Thus the additional financial resources the office will need to support the board initially will be minimal — mostly involving changes of job title and stationery.
The Council of the Society will remain the unifying body for the profession. The medicines legislation that underpins most pharmacy work is written on a UK basis. There are few physiological differences between patient populations across the country. And so the professional basis of pharmacy practice will remain essentially similar — same patients, same drugs, same problems. The Council would also deal with regulatory matters and, increasingly, with the European policy scene. The Council would set the strategy for the profession and the national boards would look at how that could be implemented within the context of the political health policy in their country.

As a new member of Council, I am trying to approach the ideal of having a national board for England with an open mind. Although the benefits of such a board may not be apparent now, I worry that the Society might look back in future on any decision not to establish such a board as a mistake that is more difficult and more costly to rectify as time passes.

Please send your comments, whether you are for or against the proposal, to the Society as part of the consultation exercise. Without your views, this difficult decision will be even harder to make.

Threat or opportunity?
The concept of devolution is not new and mention of the word still evokes strong emotions, although the Scottish Parliament and Welsh Assembly have been successfully established for a number of years. Attempts to introduce equivalent structures in England through regional assemblies have not attracted the same measure of support, however, and may have coloured opinion against this type of development. No doubt influenced by local or national experience, and an awareness of these developments within the constituent countries, pharmacists will have formed opinion on whether a devolved administration poses a threat or an opportunity to future positioning of the profession. This article seeks to allay fears that devolution should in fact be welcomed as an effective means to propel the profession well into the 21st century.

From its inception, members of the Scottish Parliament welcomed approaches made by the Society to foster close and collaborative working relationships. These have developed further and the Scottish Department is consulted frequently on pharmacy and other health care matters. However, the Department continues to be under-resourced. As a matter of urgency, it is essential that additional resource is recruited to the Scottish Department if we are to exploit fully and gain maximum advantage from these considerable opportunities. The increasing demand for help and assistance to Parliament cannot be ignored, and yet place considerable demands on the current provision. This level of participation cannot be sustained in the longer term and potentially places the profession at risk of disengagement if we fail to deliver on expectations. Consistently, Parliament wants Scottish answers to Scottish questions and is unlikely to divert attention elsewhere if these cannot be provided locally. The questions would simply not be asked or be answered by non-pharmacy interests, and that is more than likely in the competitive nature of parliamentary reality.

Pharmacy practice in Scotland is generally acknowledged as being at the vanguard of service development within the UK. The high level of engagement with parliamentarians, coupled with practitioners blessed with vision and initiative, has propelled pharmacy practice to the forefront of service development. With communication chains shorter, pharmacy thrives in this positive culture of change and innovation. Any organisation, whether pharmacy-related or not, is surely best advised to invest in those areas of practice termed as leading edge. I have no doubt that this prudent approach will enhance service development and benefit the profession as a whole.

Certainly the concept of devolution is perhaps better understood in Scotland and Wales than in England. Changing the names of the executives to boards will still maintain the principle of dedicated groups primarily focused on professional matters relevant to that country. It is likely they would continue to be designated as committees of the Society’s Council. The current arrangement, however, brings an inequity which is increasingly ineffective and unacceptable. Previously, the Council can be criticised for assuming a role akin to a national board for England. The vast majority of items debated have no relevance to professional development in Scotland and Wales.

The Council needs to deal with issues applicable to the profession from a British perspective. Matters pertinent to pharmacy services in England should be devolved to the English national board with the Council adopting a more strategic approach to pharmacy development. Increasingly, the Council will not have the luxury to dedicate most of its energy and resource to work that could be handled by a more effective and focused group.

In recent years, several members of Council have exhibited a considerable appetite and enthusiasm to initiate and accommodate major change. Although this resulted in a revised version of the Charter, that process has similarities to effect further change within the organisation. This prior demonstration of a willingness to embrace change is welcoming and should be uniformly applied to demonstrate continuance of a consistent approach rather than the adoption of selective and discriminatory style once a previous goal may have been achieved. This should not be considered as a diminution of the powers and responsibilities of Council but rather an increased expectation that, as the governing body, there is demonstration of strategic leadership — Britain-wide

Members may rightly have concerns over the costs attributed to this revised structure. These proposals feature as a redesign of existing services to equip the organisation more effectively to tackle the opportunities and threats exposed from an increasingly disparate NHS. A Council adopting a more strategic focus may have to meet less frequently, with the savings accrued from this exercise apportioned to offset the costs of the national boards. This may also take over some of the responsibilities currently held by regions and provide a more definitive and much needed level of support to the branch network.

In conclusion, I would emphasise that change is inevitable if we are to equip the organisation effectively to handle the opportunities emanating from devolved administrations.

Devolution: in pharmacy too
“What has devolution got to do with me?” Perhaps the first time most pharmacists asked that question was when the consultation document “National boards for England, Wales and Scotland: the future” landed on their doormat last month, or when they saw the two-page article in The Journal of 4 June. Well, devolution has everything to do with all pharmacists in Britain, whether resident in England, in Wales or in Scotland.

The National Assembly for Wales (NAfW), which consists of 60 elected Assembly Members (AMs), was born on 1 July 1999, when powers were transferred to it from the Secretary of State for Wales. Decisions previously made in Westminster are now decided by the Assembly for a wide range of policy and budgetary issues, including all matters relating to health. This has given the Society new opportunities to work at a closer level with the government in Wales.

There is a desire for a collaborative and consensual style of politics rather than the adversarial politics at Westminster. Changes of government at Westminster usually bring rapid changes in policy. A consensual approach as in Wales leads to greater stability and enables long term strategies to be formulated.

This new political situation of devolved government highlights the different NHS structures within Britain. The Medicines Act and associated regulation remain as reserved powers at Westminster but the Society had to recognise the differing needs and opportunities of having three governments and three National Health Services.
The NAfW has a budget this year in excess of £11.2bn, of which £4.873bn (38 per cent is spent on health and social services. Assembly Members will focus their attention on this particular budget area. The Health and Social Services Committee has a minister and a chairman from a different political party plus seven committee members representing all the political parties.

Milestones affecting the profession of pharmacy from the committee include: “Better health: better Wales”; “NHS Wales: putting patients first”; “Quality care and clinical excellence”; “Access and excellence: acute health services in Wales”; “Improving health in Wales’; the Task and Finish Group report on prescribing in Wales; “Remedies for success: a strategy for pharmacy in Wales”; the All Wales Medicines Strategy Group; the National Audit Office Wales report on “The procurement of primary care medicines”; the removal of all prescription charges; and the all Wales procurement strategy. These are just a few of the many areas that the Welsh Executive has been actively involved with speedy consultation and rapid responses.

Budgets and value for money focus minds in the NafW. About 10 per cent of the £4.873bn is allocated to primary care and 90 per cent to secondary care. The drug spend in Wales is about £625m — some £550m in primary care (about 90 per cent) and £75m in secondary care (about 10 per cent). As a profession, pharmacy needs to ensure that the pharmaceutical services provide best value for money to the patient, which is more than purely drug costs. The Welsh Executive has worked hard delivering the professional response that is credible and is not influenced by commercial factors.

The Welsh Executive was formed in 1976 and has established itself in Wales with premises purchased in Cardiff in January 1999 and a permanent secretary resident in Wales. In the words of a champion of devolved government for Wales, Ron Davies, “devolution is not an event but a process”. The Society, through its Welsh Executive, is working responsibly with that process.

It is now time for the Society’s process to move on and the Fraser report gives the framework for that. Devolution is inevitably about diversity and the three governments will develop their NHS differently at different times to serve the needs of the people they represent.

Six years after devolution there is still a culture block emanating from England whether from newsreaders and commentators in the national media or from colleagues writing in professional journals.

The NHS Plan published in July 2000 is for England only, “Pharmacy in the future” is England only, primary care trusts (PCTs) do not exist in Wales, walk-in centres do not exist in Wales. Indeed, I believe that the term “PCT” should be banned in the corridors of Lambeth, and we should use a generic term like “primary care organisation” so that Scotland and Wales are not excluded.

The Society is the Royal Pharmaceutical Society of Great Britain not England, and the reserved regulatory functions will remain as a core central activity. However, the professional role needs to interact credibly with its major partners including the three National Health Services of the home countries.

The role of the Council of the Society is to provide leadership and high level strategy and policy. To guide, establish and deliver this policy executive boards in England, Wales and Scotland need to be clearly defined so that there is effective two-way communication that delivers value for money. Wales and Scotland already have a clear starting point but England is being left behind. The Society has to recognise that policies must be applicable to each of the three home countries; it is not credible to take along GB policies to the NAfW that for example refer to PCTs only!

Devolution is about engaging the people more at a local level, and the Society should note that both Scotland and Wales have better engaged with pharmacists than has England. This is reflected in the higher percentage voting in the recent Council elections for the reserved seats.

Structures only need to be tweaked, eg, make better use of the branches and regions for an English board to engage pharmacists and give ownership to our professional body. Council should be involved with high level policy delegating work to the boards.
My vision is based around the simple analogy of a milking stool, the seat is the overarching Council, the legs are the three executive boards and the spokes which strengthen the structure even more are the committees and expert groups. Take away one of those legs and the structure is unstable. — Colin Ranshaw, Council member for Wales.