We’ve seen pharmacies close down but the ones who are surviving need to do more, says Dr Jagan John. The Barking and Dagenham clinical commissioning group chair talks to Neil Trainis…
Dr Jagan John is not afraid to voice an opinion. As a GP who heads up Barking and Dagenham clinical commissioning group (CCG), one might say his utterances carry some weight.
The mind drifts back to November last year when he suggested with some conviction during a north east London local pharmaceutical committee (NEL LPC) event that pharmacy’s business model was “not fit for purpose any more.”
Delivered before an audience of pharmacists and pharmacy body representatives, it was not a claim that drew any gasps. The silence that followed seemed to suggest they could not argue with it.
Dr John makes it clear he is a friend and fan of community pharmacy but he makes no apology for his comments.
“It was in the scope of, not in the respect that pharmacies are rubbish in any way, that actually, they are a vital part of our community,” he says in a quiet room away from the commotion of people darting from place to place in the name of healthcare at the Ilford headquarters of Redbridge CCG.
“I think the concern that I was raising was, from my patients and GPs and colleagues, was that unfortunately, we are seeing some of our pharmacies closing down and the feedback we get from our pharmacists is it’s a difficult business to be in any more and now they are moving on.
“For me, it’s a well loved community asset, it is a highly regarded group of professionals and the question from my point of view is is the modelling wrong, do we need to think about much broader elements being part of a collective, integrated system, the integrated care systems, to be a part of that?
“And then modelling them, for example in social prescribing, and saying ‘could they be hubs or community centres?’ Yes, they have their pharmacy role and they have the functions but broadening that horizon of the pharmacy, the fact they are just there right in the midst of that community, that’s what I’m saying.
“We need to be thinking collectively about a much wider exploration of, not just the pharmacists as clinicians and experts in medicines management, but actually looking a little bit wider.”
Dr John suggests pharmacy’s “modelling needs to be wider” and believes social prescribing, the government’s way of helping people deal with feelings of loneliness and isolation as outlined in its 10-year plan, is a significant part of that.
The point of social prescribing is that it reduces, and in some cases, removes the need for medication. It addresses the social, economic and environmental factors behind poor health rather than prescribing people with drugs.
Pharmacists, nurses, GPs and other healthcare professionals can refer them to what the King’s Fund describes as “local, non-clinical services” and “social prescribing schemes” which include sports activities, arts and cookery classes, gardening and group meetings where people get the chance to make new friends. And it encourages them to take greater control of their own health.
Caution that pharmacies must provide services beyond dispensing is well worn but there is something fresh and compelling about social prescribing. Because it has not been described clearly to pharmacists up and down the country it is, for many of them, tinged with a little bit of the unknown.
Dr John, who describes pharmacists as “our consultants in the community,” insists that is not so true of pharmacists in London where talks on getting them involved in social prescribing have taken place.
“Across London there have been some conversations regarding social prescribing with pharmacies,” he says when asked if pharmacies in Barking and Dagenham and the surrounding area are making progress with social prescribing.
“We haven’t tested pilots yet simply because of funding but I think if government changes are imminent with the long-term plan going forward, I think there is a scope for looking at pharmacies in a very different light regarding social prescribing. So in Barking and Dagenham, that’s something I would love to explore.
“From the Healthy London Partnership’s element, I understand that pharmacies in general have been quite willing to have that dialogue going forward across London. Social prescribing is one of those things that some areas do very well, like Merton and Tower Hamlets.
“Barking and Dagenham is just starting and Redbridge has got a pilot funded by the Department of Health. It’s whether we explore that further with our partners.”
He is asked if it is a case of selling social prescribing to pharmacies.
“Yes. We regard networks of GPs, for example, around 50 to 70,000 in the King’s Fund model and the network also includes the community providers. And it’s having a look at all those providers in those localised areas to say ‘what could you do to help our situation’ because we have rising costs in A&E, we have rising costs in outpatient activity, we have GPs buckling under the pressure in terms of demand.
“And I’m not saying pharmacists aren’t busy. They are very busy but it’s just whether we collectively say ‘these are the functions of our landscape we do collectively in that localised population,’ so our voluntary sector, pharmacists, our community providers, our GPs and of course any other service that comes with that.”
The health secretary Matt Hancock recently unveiled plans to introduce social prescribing academies which would underpin the social prescription model.
Dr John is reminded that he told the NEL LPC event he hoped community pharmacists were “future members of that academy.” He is asked if pharmacies in Barking and Dagenham and the surrounding area even know what a social prescribing academy is.
“Who’s in the academies, we don’t know the details. Pharmacies should be part of that social prescribing academy. If we are going to have a national system of social prescribing, for me it’s about using the assets of the community and allowing people to give us a slightly different level of care.”
There are concerns some community pharmacists will not have the time to engage with social prescribing. Others may not have the appetite. Pharmacy’s remuneration for its part in the initiative has also not been set out plainly.
“I think (pharmacists) will (get involved). I think there will be an uptake. I was recently quite impressed that some of our pharmacies in north east London were going through to the Mary Seacole Leadership Programme locally. That’s something they’re doing on their own back, to be leaders. That’s fantastic,” he says.
“They’re taking the initiative to be leaders across the system. Part of the academy is also about being leaders in social prescribing.”
Dr John concedes he does not know how many pharmacies on his patch have put themselves forward for the leadership programme but adds: “I just saw it on Twitter from (NEL LPC secretary) Hemant Patel saying that they’re all applying. It just shows you the willingness and the enthusiasm of our pharmacy colleagues are trying to go forward and do things differently and become leaders, getting official training.
“For me, that’s a very positive element because social prescribing, being an important future mechanism, is a very important part of that solution.
“The social prescribing link workers are what we regard as the person who is connecting with the local community, usually through the voluntary sector and so on because they have the skill-set, resources and knowledge. But there is something about pharmacists being involved with those different methodologies.”
Profit is not a dirty word, especially for community pharmacies trying to stay afloat in the wake of crippling funding cuts, and some pharmacists may think ‘there’s little or no money in social prescribing. Why do it when I can be concentrating on dispensing and other local services and making money that way?’ Dr John does not hesitate.
“I understand this and there’s something about learning. There’s part of me that says ‘it’s going to be the big thing for the NHS, I can guarantee you that.’ We have the same issues in general practice. General practice says ‘I don’t have enough time in the day to even consider social prescribing.’
“There are different methodologies. You can be very involved, then there’s people who are aware of it and signpost to social prescribing.
“There’s something about being visible. One thing social prescribing does do, it makes you visible as a clinician and as a service in the area. If you look at our number of medication error-induced admissions, in spite of having lots of players involved, we still haven’t managed to reduce that.
“You just wonder if a community pharmacist is involved with these schemes, the other skillset they have is actually tackling the things they get…so there are always wins that we just don’t see across the system in terms of dispensing, medication reviews.
“Being involved in schemes such as social prescribing, understanding gaps is really important. Sometimes we don’t really know the gaps. It’s only if you get involved do you understand A, the solutions, and B, identify what’s missing. So there may be commissioning gaps or other things they can get involved in.
“What I’m saying is get involved. You don’t have to be involved completely but it’s going to be a big social movement. Fundamentally, it’s going to affect the way we do business in terms of healthcare as well as social care.”
Listening to Dr John, it feels as though pharmacies simply cannot afford not to get involved with social prescribing.
“I think that’s probably overstating it. There will be the enthusiastic leaders in pharmacy that will be involved from the beginning. It is a movement. It’s going (on) across the country. If they are not involved initially now and they are sceptical, that’s fine.
“At the same time, I think in time, they will understand what’s going on and will probably be late comers on to the movement.”
His message to community pharmacists? “People like myself respect you and want you to be part of a new system of healthcare where we’re looking at proactive care meaning not reactive but saying ‘get to a problem before it becomes a problem regardless of what it is, whether it be your housing to your health needs.’
“You and I know that life in general is a collective set of circumstances. If your housing (is poor) and you’ve not got enough money and you’ve got a long-term condition and you’ve got mental health issues, you’ve got to deal with all of them. You can’t deal with one and that unfortunately is the NHS model.”
He detected enthusiasm for social prescribing from the pharmacists who attended the NEL LPC event.
“Hemant Patel asked if we can sit down and have a meeting to discuss this further, which I will be arranging. And I had numerous pharmacists who individually said they are very happy to have a conversation but doing it through the LPC for me is a bit more of a structured methodology in terms of having a dialogue, then getting the interest.
“I think where the government direction will probably go, it will be all about population-based healthcare. And if it’s population-based healthcare even if it’s at a locality, network level, it will be all about how the whole system will be about the population base and there will be lots of initiatives to try and help that integration.
“My point is that, yes you’ve got a contract in the pharmacy, but it’s not just about your contract. I want to work with you to see if we can expand that and go back to the people at the top and say ‘actually, we’ve got a better model and our pharmacies are a part of this.’”
The PSNC’s talks with the government on shifting the contractual framework from dispensing to services could, in Dr John’s eyes, include persuading ministers to incorporate social prescribing into the contract so pharmacists are properly remunerated for it.
“Of course, nothing is for free. Even though I’m not part of (the pharmacy contractual framework negotiations), it’s just my view, there would be some enablers within the pharmacy contract to allow them to be part of that system which, at the moment, has been on the goodwill of pharmacists locally.
“We’ve had some fantastic pharmacists locally who are just dynamic individuals who are very much involved in their free time above and beyond.
“Being confrontational about the contract was only because I wanted people to say ‘you need to do more out there.’ We have a collective responsibility to say to our masters ‘actually, we think we can come up with a formula, whether it be local across north east London, to say we can embed lots of the programmes like social prescribing and allow people to use the pharmacy as a community expert or centre to try and push things forward.’
“I appreciate I don’t understand all the dynamics of the (pharmacy) business model but I don’t want to lose this fantastic workforce that is highly respected, loved by the British public.”
He is asked if he would like to see the GP and pharmacy contracts merge.
“I don’t know, I’m not sure because obviously the contracts are slightly different in terms of what the expectations are but at the same time, there are schemes where pharmacists are working in practices, community pharmacists, some of them are dedicating their time into practices in their local area to help support…things are changing where pharmacists are part of the workforce and equally, GPs are part of pharmacists’ workforce.
“In some areas, part of the GP training, they have their GP new trainees going into pharmacy and spending days there. So the mindset is changing to say ‘we think this person is really important for you to understand the kind of issues they have to work on.’ That collaboration is really important.
“North east London particularly is working on ways of improving our GP training and part of that is having real interaction with our trainees with pharmacy in general.
“The government are the people can only talk about the contracts, so to answer your question, I don’t know. But there will probably be collective contracts across the system which allows certain financial benefits and it won’t be particular things, it will be on a collective area going forward I envisage.”
Does he detect an appetite among his GP colleagues for a joint contract?
“No-one’s really said anything because they’re very worried about the contracts. I do know there is a huge amount of interest now across London about pharmacists in practices and vice-versa and not specifically to always be employed by the practice but working collaboratively having those kind of arrangements.
“The view about pharmacists is changing quite considerably. Where we, in our own practice, had employed an outside pharmacist to come in who had another job somewhere else, we found it hugely beneficial.”
Dr John’s enthusiasm for pharmacies’ role in social prescribing is unsurprising given their location in the heart of their communities. Very often, they are ideally placed to help hard-to-reach people with mental health problems who have little or no money and live in poverty.
The government too has, at least verbally, recognised the value of pharmacies to localities even if it seems perversely keen to reduce the community pharmacy network through its swingeing funding cuts.
Dr John estimates “a handful” of pharmacies have closed down on his patch.
“I do know the impact it has on the patients because on various forums, be it the local authority or at patients directly, that they get quite upset.
“I know there’s a pharmaceutical needs assessment that picks out any kind of issue in terms of capacity but it’s the physical loss that people find.
“Speaking to some of my colleagues across the country who happen to be pharmacists, they’re saying ‘it’s a very tough business now’ with the high street in terms of the funding cuts and the internet explosion which has impacted on the high street.
“High street shops are impacted by the whole internet revolution. There are certain things that the pharmacist would traditionally sell other than, or do business on…it’s becoming hugely impacted, that’s the feedback I get.”
Chat soon turns back to that ‘pharmacy model is not fit for purpose any more’ assertion. He is asked if he based that assessment purely on pharmacies in Barking and Dagenham or on a wider area than that.
“The traditional pharmacy model that we have is not fit for purpose in terms of, and I’ll be very clear on this, it’s about the fact that they could be doing a lot more across the country, social prescribing, getting involved with communities, that’s where I say the model could change.
“And I think there’s a certain amount of the pharmacies in general as a collective system saying ‘we’re ready, we’re willing.’ I know the LPC in our local area have made that very clear, that ‘we’re willing and able to do more. But let’s have a dialogue.’
“That’s the question we need to push forward, that on a national level, the dialogue needs to happen, things like social prescribing. We’re trying to harness the community from the voluntary sector as well as the assets. We need to think about a slightly different model for the existing services.”