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At the All-Party Pharmacy Group meeting in November 2007, health minister Dawn
Primarolo promised that the expected pharmacy White Paper would be aligned with the Lord Darzi’s review of the NHS in England and would join pharmacy policy with the rest of NHS thinking and planning. It is an ambitious aspiration, but one that is long overdue.
The APPG inquiry identified many of pharmacy’s barriers to progress
and proposed solutions. The Government listened and recognised the good
sense of many of its recommendations; hopefully we will see echoes of
the inquiry in the White Paper.
Today pharmacy has a wide range of professional tools available to it
in the form of enhanced pharmacy services, pharmacist prescribing and
pharmacists with special interests. But unless these tools are put into
practice in the context of a commissioned service, their existence will
be meaningless.
Commissioning policy is central to achieving change in the NHS; but it
is also central to pharmacy’s aspirations to expand and develop.
This is where pharmacy policy and the bigger NHS picture converge.
Governance challenges
The NHS commissioning environment is evolving. In the past 12 months,
we have seen how current commissioning policy is translating in practice.
It is clear that practice-based commissioning is not delivering significant
change for patients and that it is rife with governance challenges.
There
is evidence that “choose and book” is being manipulated
to protect the interests of legacy providers by, for example, making
it difficult for GPs to find listings for private hospitals within
its software (Financial Times, 27 January 2008, “Code
to promote the use of private hospitals”). There are powerful forces at
work, and they are resisting change.
But not for long. Chan Wheeler, the new commercial director at the
Department of Health, has promised that from April 2008, when a new
marketing code
is introduced for NHS providers, such restrictive practices will no longer
be tolerated; and there will be “a non-discriminatory view of choice”.
This sounds promising. But in primary care, such a level playing field
between providers remains a pipe dream.
The pharmacy White Paper and the Darzi review provide an opportunity
to address this and increase the chances of pharmacy services being commissioned.
For us, achieving a level playing field in primary care should be non-negotiable;
and it happens, it will prove a major barrier to the delivery of an expanded
clinical role for the profession.
Our thinking at the Company Chemists Association has led us to the following
conclusions. Get policy right
First, we want the NHS to get commissioning policy right. We want a
level playing field between primary care providers, and a commissioning
environment
that is fair, transparent and delivers value for money. Any providers
who prove themselves competent and willing to provide should be considered.
And the elephant in the room — the political power base of incumbent
providers — must be addressed.
That said, we need clinician involvement in commissioning. But this
input needs to be professionalised. We see this as a new skill base,
and we
are calling for the introduction of an NHS management competency programme
for healthcare professionals engaged in commissioning, including pharmacists.
We also want a new cross-provider incentive scheme that rewards investment
in
service redesign and innovation. This would replace practice-based commissioning
but retain its core principle that providers who help improve use of
NHS resources should share the financial benefit this brings and be enabled
to reinvest their share of the savings in patient services.
We would
also like to see this principle extended to the reimbursement system
for community pharmacy so that if, through its effective purchasing,
pharmacy saves the NHS more money than expected, some of that money is
recycled into patient care provided from pharmacy.
We believe that a major weakness in the current system is the marginalisation
of secondary care from the commissioning process. We believe that service
redesign only works if everyone wins. So we are calling on the NHS to
explore the concept of “integrated commissioning”, first
proposed by The Nuffield Institute (“Commissioning
in the English NHS: the case for integration”, The Nuffield Trust, 2007) that
would see commissioning evolve into a multidisciplinary process that
facilitates collaboration, and is inclusive. We believe this model would
help the NHS achieve swifter progress on redesigning care closer to home.
We also want to see provider incentives created so that primary care
trusts can facilitate, encourage and reward collaboration between pharmacists
and GPs.
We believe that the general medical services quality and outcomes framework
(QOF) should drive general practice activity to focus on case management
of people with multiple conditions and the provision of care closer to
home, leaving the management of those with chronic conditions and minor
ailments to pharmacists.
Over time, we believe that primary care contracts
should be more closely integrated and we would like the feasibility
of doing this explored sooner rather than later.
We also believe that there is a need to clarify competition law in the
context of primary care. GPs are in the process of setting up provider
consortia to contract with the NHS for primary care services. In many
cases, these consortia will constitute a monopoly — or at very
least a market dominant — provider within their locality.
Despite
the attractions consortia hold for commissioners, as a sector highly
sensitive to the constraints of competition law, pharmacy has been reticent
about embracing this organisational model.
UK competition law prohibits any business practice that enables a provider
to exploit a dominant market position. We believe that primary care provider
consortia do this. But since the NHS is an atypical market, this does
need further clarification. The key thing is that the rules of provider
engagement are clear and consistently applied.
We would like the DoH
to clarify “acceptable” organisational models for collaboration
between providers so that no primary care provider is in danger of knowingly
or unwittingly breaching UK competition law. Reward mechanism
We want to see innovation in service redesign rewarded so that if a
provider invests in service development, there is a clear mechanism in
place
to reward the risk that this investment represents.
And we want to see greater access to “private” primary care,
with the NHS scoping through consumer research a range of medicines and
services, which the public would like easier access to and would be prepared
to pay for. This recognises the trade off that people increasingly make
between price and convenience, and might allow the NHS to refocus some
resources on areas of greater need.
It does not look like the standard policy shopping list and neither should
it. This White Paper will be about putting pharmacy into the bigger picture.
It is time to look beyond the confines of our own world.
Are we up to
that challenge? |
The
Pharmaceutical Journal