The pharmacy experience has been an eye-opener for Mark Lyonette since he arrived at the National Pharmacy Association. Its chief executive talks to Neil Trainis…
If a week is a long time in politics, a year in community pharmacy might be described as tumultuous. Not that Mark Lyonette shows any signs of scarring 12 months into his role as chief executive of the National Pharmacy Association (NPA).
“I’ve loved it actually. It’s been an amazing year. That’s a very difficult thing to say when you know how much our members have been suffering,” he says, quickly dismissing the idea that he must have wondered what he had walked into after spending over 20 years at the Association of British Credit Unions, 13 of those as chief executive.
Community pharmacy, after all, has had to contend with all manner of upheaval, from government funding cuts and medicines shortages to changing local commissioning structures, large-scale NHS reforms and increasing workload on squeezed budgets.
“I’m not saying it’s been an amazing year for community pharmacy but for me, coming into a new sector and only ever having had a patient’s perspective, when you walk into the pharmacy, unless you have an extended interaction, I don’t think you really have an understanding of what the profession is and what it does and how it benefits society. For me, that’s been fantastic.”
In a small office in the NPA’s headquarters in St Albans, Mark gives the impression things have so far gone smoothly for him at the NPA, even though he playfully observes that “something like 41% or 44% of chief executives” in general “don’t last 18 months.” The pharmacy experience has been an eye-opener for him.
“Getting the chance to visit some of our members and see the things they do and see some of the differences in some of the countries, all of that’s been fantastic.
“But I would contrast that with recognising it’s not been a fantastic year for our members, not just those in England. Shortages are pretty much a problem everywhere.
“The main part of my job, running a trade association, running a membership body, that’s what I do and feel very familiar with the dynamics of what that looks like.
“You’ve got to find the best way to focus on what members need, try and understand the board and the board’s relationship with members.”
Mark is asked how he has got on with the NPA board.
“The board was my first experience of our members because as well as being my board, they’re all community pharmacists and community pharmacy owners. They were many of the first pharmacies I visited.
“I remember the very first counter I walked behind. I was shocked I didn’t have an understanding of what’s happening. There is a job to do which I think many pharmacy bodies recognise about explaining what community pharmacy does and the value it brings to patients.
“So that was my first experience of board members. As a board, when I arrived they showed all the things you might have expected if you had to guess of…they didn’t have a chief executive for a couple of years, people get used to working in a way.
“Working without a chief executive is definitely a thing. There was more interaction between board members and lots of staff than you would typically see once you have a chief executive. The chief executive becomes the accountable person if you like to the board.”
One of the charges that has been levelled against the NPA board in recent years is it has involved itself in the running and management of the organisation when its focus should be on policy, strategic direction and objectives. Mark is asked how an NPA chief executive overcomes that.
“I come from a particular perspective around governance and management. Some of my peers in previous roles in other organisations, friends, they kind of start from ‘this is the board’s role, this is the chief executive’s role.’ While I can see the appeal of having that easy template, I don’t start from that basis.
“My background in governance is very much around policy governance where I start from ‘actually, the board has all power until the board gives any of that power away.’ When I say power (I mean) decision-making.
“The board has all power in any organisation and the key part of it is the board must be clear what they are delegating, what responsibilities are they giving to the chief executive and when those are clearly defined and delegated, then the chief executive can be held accountable.
“But I don’t come from that school that says ‘that’s the chief executive’s job and that’s the board’s job.’ You get there eventually but the board has to give power away if that makes sense.
“Different companies do that in different ways, different board members will have different understandings, so it’s really critical that any board has clarity and has that discussion internally because what’s particularly important in a membership body is that the board speaks with one voice.
“Sometimes a board can speak with however many members of the board you have, in our case 17, and that becomes very difficult. But I think the board and I worked well through all of that.”
The NPA has arguably suffered from a lack of stability in the last decade or so largely because it has not had a long-term chief executive. John Turk was there for two years before resigning, Michael Holden left after less than four years and the organisation went three-and-a-half years without anyone in the role.
“I’m more interested in where we are today and how we can support members, however, yes, it’s kind of factual that we have had quite a lot of chief executives in a period of time,” Mark says.
“I’m not sure I could speculate why but, and I think I said this to the board after I started, you might be surprised how often chief executives don’t last very long. Not pharmacy but generally.
“That’s quite a sobering thought and I said that to the board really early on because you want to put in place things that are going to help with that. Often, if you read and listen to why those things are the case, it’s often perhaps the board underestimates the transition of one chief executive to another, particularly if that’s a long-standing chief executive, or in our case, even harder perhaps, the transition from having no chief executive to a chief executive, the changes you need to put in place.
“It isn’t an easy transition and if you don’t get it right and you don’t put the right support in, people can end up parting ways for whatever reason.”
Mark is asked if the NPA is in need of streamlining and, having come into the post overseeing 120 staff, whether he will need to cut jobs.
“No, I don’t think I’d describe… I’m a big fan of Jim Collins, ‘Good to Great’ and all of that. I think it’s really important that any organisation gets the right people on the bus,” he says.
“It’s actually, in some circumstance, more important to have the right people on the bus almost before you decide where you’re going and so you ask ‘who’ rather than ‘where?’
“I’m coming in new, finding my feet with all my colleagues and I’m very keen that we build a strong team here. Like any organisation, sometimes you’ll find gaps where you’ll think ‘we need to be a bit stronger there.’ You evolve, you change.
“I wouldn’t describe us as streamlining. I think the Association has always got to make sure, like any company, that income meets expenditure. We’ve got something like 130 people. At times in its history, the NPA will have more staff or less staff.”
Insisting the NPA is “very well capitalised,” Mark adds: “Over 98 years, we have done well. We’ve built good reserves and that’s just critical if you’re running an insurance company. One of the key things, and it’s something that has tightened in the last 10 years, (is) a lot of insolvency regulation which came from the EU.
“So it’s really critical we keep enough capital and don’t touch any of that so the insurance company is well protected because the nature of insurance is risk and sometimes you might have a bad year and all of those things.
“I think we are in really good health. My job in all of that is to make sure that year by year, we are in a profitable place where actually, that doesn’t get destroyed.”
Mark does not subscribe to the view that community pharmacy’s health is beyond repair, insisting NHS England “has a clear view of integrating community pharmacy into primary care networks.”
Yet he is inspired by the attitude of the chief pharmaceutical officers for Wales and Scotland towards community pharmacy.
“We had a day in Wales recently with Andrew Evans, the chief pharmaceutical officer, and it was really inspiring.
“We visited maybe five pharmacies and to see the interaction, and I’d say this is something that defines the role of the chief pharmaceutical officer (and) their vision for community pharmacy and is so, so critical, but to see Andrew happily interacting with our members in Wales, not just saying he was listening but really listening to what members were saying, you could see members respond to that.
“Andrew says a number of fabulous things that I quote all the time. One of them is he talks about the clinical value of community pharmacy but he also talks about the community value of community pharmacy and the Welsh government recognise that in many parts of the country, that is as important as the clinical role community pharmacists play. That’s not necessarily the case in England.”
Mark insists “you get a similar vision listening to Rose Marie Parr (Scotland’s chief pharmaceutical officer), that absolute clarity and passion about the value of community pharmacy.”
There are concerns about NHS England’s attitude to community pharmacy, specifically independent pharmacy. A recent £9 million scheme to identify people with atrial fibrillation will involve pharmacists based in GP surgeries, not community pharmacies.
And for a while it was unclear that primary care networks (PCNs) would involve community pharmacists. One wonders how many NPA members have so far struggled to make inroads with PCNs.
“We don’t know at the moment. When we sat down (in April) with the BMA (British Medical Association) the message was don’t panic. One of the things that’s going on at the moment is the documentation and paperwork for PCNs and the GPs are getting all that sorted.
“It’s easy to think you’re being pushed out when all they’re saying is ‘we haven’t got to that discussion yet.’ Remember, PCNs were given a very tight timetable.
“Nevertheless, it is early days and we’re very encouraged with what we’re hearing from NHS England about potentially requiring PCNs not just to engage with community pharmacy but demonstrate they have integrated with community pharmacy.
“It would have been good if we could have heard some of those messages in January when the GP contract came out. That would have been reassuring for members because members felt this was all about pharmacists in a different setting.”
NPA board member Hemant Patel said local pharmaceutical committees across England need a combined £3 million a year if pharmacists in their areas are to get involved with PCNs.
“I think I agree. I was talking to Hemant in Edinburgh a couple of days ago and you can’t fault the thinking and the numbers. It is one of the challenges. We don’t have a great package of support for that kind of activity,” Mark says.
“I know it’s very easy to look over the fence at the GPs and say ‘they get supported with this and that’ but I don’t want to focus on what the GPs get. The message from us is ‘if you want community pharmacy to be able to do this, you’ve got to support the sector in a way.’
“There’s a couple of elements to that. One is attending meetings and being structured in a way, whether that’s federations or provider companies but the other part of that is, and this links a little bit to the contract negotiations, giving enough clarity about a multi-year, maybe even a five-year perspective, so people can see the value of them investing in this and finding the time.
“At the moment it probably feels a little confused and you’re not quite sure what’s what. If government really wants us to live up to that vision, provide a greater range of services, utilising the skills of our pharmacists, then it would really help, particularly the owners, to say ‘this is what we’re doing this year and this is where we’re going next year.’
“I’m not naïve, I realise we’ll have to demonstrate a business case for that and that’s probably as much about Treasury as it is the Department of Health but we should be able to do that.”
Many NPA members, Mark insists, “are in a really difficult place,” struggling to make ends meet.
“We haven’t yet seen hundreds of closures but as I listen to members and they talk about the payments from NHS not covering the drugs bill let alone covering staffing and other costs, it is only a question of time if we continue like that before we have some major problems.
“We’ve published our financial survey of members and it’s not just quantitative, there are a lot of qualitative things as well like levels of stress, but some critical things as well like how often have you had to ask for greater credit terms, how often have you not been able to pay things on time.
“I met one couple in the North East and they’re just doing huge, long hours. They are just about keeping it on the road but is it more stressful, more unsatisfactory for the team to be working that long? Yes. Then we have to be careful this doesn’t turn into a patient safety issue.
“I’ve seen some shocking sets of accounts and it’s not just our smallest members. I’ve seen some shocking sets of accounts from some of our bigger groups with tens of pharmacies.”