The push for local commissioning is laudable, but how can it possibly work, asks Mukesh Lad, chairman of the LIPCO federated group
NHS England chief executive Simon Stevens wants to push forward with local commissioning to meet local healthcare needs. That’s all well and good. In theory, I commend him for this approach. But how can this work in practice? Community pharmacy operates, for the most part, under a national core contract from the Department of Health (DH). The inherent expertise pertaining to our professional role therefore resides with civil servants who often rely on the advice of our representative body, the Pharmaceutical Services Negotiating Committee (PSNC).
How then can anyone expect commissioning at a local level, managed by generalist procurement agencies, to provide a fair and equitable service for any of the interested parties? Local government departments have limited understanding of the fundamental mechanics of the pharmacy contractual framework and even less appreciation of the nature of NHS healthcare. Pharmacy ‘service users’ are patients. Patients are people. And people aren’t just data to be balanced at the financial year end!
No EHC, no fee
A recent clinical services procurement in Leicestershire saw the local public health commissioners setting a minimum level of delivery for Education, Health and Care (EHC) interventions. For a community pharmacy to be successful in its tender to provide a free NHS emergency contraception service to under-25s, it has to guarantee a minimum of 10 emergency contraception interventions in a year. Where is the public health provision in that? It goes without saying that we’re neither able to predict, nor encourage, a person to require this service. Added to which, we have the moral issue of not wanting to actively promote a service that many may feel encourages promiscuous behaviour.
This is a so-called ‘payment by results’ commission, ie, no EHC, no fee. Surely preventing even one unwanted pregnancy is far more worthwhile than keeping the procurement paperwork in order? I would further add that these restrictions have been imposed in the county where sexual health services are far scarcer than in a city centre. Did the term ‘health inequality’ become a victim of the funding cuts as well?
This abject lack of understanding of healthcare runners and riders isn’t just limited to local commissioners of pharmacy services. We can find more blinkered contenders in CCGs than in the Grand National…Well, it was sponsored by Randox Health!
The use of branded generics – so actively encouraged in the false hope of making savings on drug budgets – doesn’t take into account the management costs of script switching. That’s a human resource or ‘outside contracting cost’ and a separate budget from the one “lining the pockets of those fat-cat pharmacists”. Little do those decision makers realise, or even care about, the negative impact it’s having on pharmacy funding up and down the country. By perpetrating the ever-widening use of branded generics, the CCGs are preventing pharmacy from accessing its equitable share of the global sum that’s distributed through its dispensing of category M generics. I suppose we always have the profits from our sandwich sales to fall back on! If only we could afford to take that belief on the chin and joke about it, eh?
Altering the repeat prescription ordering process is another fine example of shortsightedness. Asking the patient to order directly from the GP surgery is nothing short of inefficient and time-consuming. Added to which, the merits of any financial savings have yet to be proven. The impact on patient health from not getting the right medication at the right time has undoubtedly not been taken into consideration either.
Many pharmacies are already reporting a considerable drop in the number of prescriptions for low value items. Yet others have seen no difference at all because their prescribers don’t see the logic in implementing this policy. It’s little wonder that patients are becoming more and more confused. And it’s the pharmacy that always gets the blame – not the DH, not the local commissioners.
An elderly lady recently came into my pharmacy after visiting her GP. She was in a great deal of pain and discomfort and was prescribed medication. She was also told to buy some paracetamol tablets. On leaving the surgery, she’d booked her follow-up appointment at reception. She also ordered a repeat prescription for her disabled husband, which included paracetamol tablets. Is this really health and social care when a vulnerable person in her 80s has to try to understand why she has to buy her paracetamol but her husband doesn’t?
I realise we’re all under financial pressure in proportionate measure. From the DH to the local authorities, I appreciate there’s a funding crisis. What I cannot accept, however, is the total lack of vision and common sense. For whatever reason, be it political, practical or professional, not one decision maker wants to accept that community pharmacy can be a partner in the delivery of effective healthcare. Nor do they want to achieve a better understanding of what we can achieve. So at best, we’ve become a commissioner’s afterthought, a convenient way of mopping up behind their original ill-fated choices. At worst, we will be adding sausage rolls and ice creams to our sandwich lunch deals! It’s a sobering thought, isn’t it?