Most local pharmaceutical committees have made a start on their primary care network journey, says Michael Lennox. The man tasked with helping community pharmacies integrate into the new structures talks to Neil Trainis…
Two things appear to weigh on Michael Lennox’s mind. One is community pharmacies’ integration into primary care networks (PCNs). The other is music.
“My son’s a professional musician. He’s in about three or four different bands. He kind of occasionally trades in one guitar for another and he did a really good deal on this limited edition, beautiful Fender Strat,” he says enthusiastically in a small office at the National Pharmacy Association’s (NPA) headquarters.
Michael’s desire is for community pharmacists to play in rhythm with PCNs across England having been given responsibility by the NPA and PSNC for ensuring community pharmacy is not left on the side-lines as local integration lead.
“We’re trying to help community pharmacies integrate into PCNs primarily by supporting the leadership organisations to be able to support the local pharmaceutical committees (LPCs) to more effectively support the pharmacies,” he says.
“With the NPA, there’s a sort of a directness of ‘how can we help our members navigate this?’ In my PSNC role, it’s ‘how can we help and guide LPCs to enable this?’ So it’s kind of a twin track.”
Michael insists that as Somerset LPC chief officer, he was in “a very privileged place” because the county had a head start when it came to community pharmacies forming strong bonds with PCNs, which have general practices at their core but are being driven by a range of health professions as care is moved out of hospitals and into local communities.
He is asked what progress he has seen community pharmacies across the country make with PCNs.
“It is too early to say. Like everything in life, it’s a normal distribution curve. There are 1,259 PCNs that have been contracted for. That covers 99.8% of all GPs. So we know that our brothers and sisters in general practice have said ‘ok, we’ll jump on the bus and go on this journey.’ Now, that wasn’t a given.
“Down in my patch in Somerset, it was dead easy. The clinical commissioning group (CCG) did a brilliant job, the CCG harnessed the GPs, worked with the LMC and managed to get a map of what the PCNs would look like way back before July 1 when they were signed off.
“So it depends on the health economy and how it is enabling the PCNs. But pharmacy cannot jump on the PCN bus if the bloody bus hasn’t been built. What you can do is go ‘I quite fancy making a journey with you’ and you can put down the flagging messages.
“But I was in a very privileged place in Somerset because prior to PCNs, the National Association of Primary Care had a programme called primary care homes (PCHs) and the PCH programme was like a precursor to the primary care network construct.
“Actually, there were two to three hundred PCHs already there. So ahead of the PCNs forming, there was this precursor, if you like the chrysalis before the butterfly, and Somerset was choc-a-block full of primary care homes.”
Survey discovered complexity of PCNs
The impression is that community pharmacies have so far achieved varying degrees of progression with PCNs across England. Michael spoke to LPCs to find out what their struggles were and what support they needed to make inroads with the new structures.
“I talked about supporting the LPCs through my work with the PSNC. My first piece of work was to find out what the reality is,” Michael says, pushing a bundle of papers across the table.
“This 46 pages was a really in-depth, under-the-bonnet survey of all 69 LPCs saying ‘where are you at?’ Who’s filled it in, how complex is your health environment, how many STPs (sustainability and transformation partnerships) are you in, how many CCGs, local authorities, how many PCNs are you operating in?
“So we went under the skin in this survey to find out what the complexity of what our LPCs were trying to navigate would look like. Once we understood the complexity and had asked them to give us a bit of narrative, we then said ‘what challenges and barriers are you facing into?’
“And they came back and said ‘these are our challenges.’ We came and said ‘what support do you need?’ What was really interesting was we then said ‘ok guys, are you making progress to integration? Are you beginning to get linked into these new constructs?’”
Pointing to the bundle, he says: “These were the results. The results are it’s early days but actually, most LPCs have made a start on this journey and some are further than others but if you were to take the herd of 69, it’s a pretty low start understandably across England.
“We then said ‘as well as your integration journey, what progress are you making? Are you beginning to have influence? And again, some of them said ‘yeah.’ And we’re saying yes to some of these indicator questions.
“So we have begun to put a little bit of object of finding out and you cannot do the doing if you don’t know what the findings are. All LPCs are making some progress, all LPCs are being supported by the PSNC.
“The NPA is going to dial up what it does to support LPCs as well as its members because the LPCs are probably the key to this.”
Michael was very clear during this year’s NPA conference that contractors need to be up-to-date on the latest developments, citing NHS England’s guidance for LPCs, How to help contractors get involved with primary care networks, as a must-read.
One wonders if all LPCs are capable of helping community pharmacies link with PCNs given the quality of some has been questioned in the past.
Ash Soni told the NPA conference in 2011 that LPCs were not fit for purpose “in the majority of cases.” Two years later, then Numark managing director John D'Arcy said there were LPCs who were “brilliant, not so brilliant, medium, below average and there'll be some s**te. It depends on the individuals.”
LPCs are on a journey of development
Michael does not have concerns that LPCs are ill-equipped to drive PCN engagement.
“Having interacted with every single LPC in the country as I built this survey…I built the survey with a couple of dozen of them and then I spoke personally to every LPC in the land about the survey and about how they were feeling and what they were thinking.
“All LPCs get this. I would say LPCs are on a journey of development but this is not easy.
“Honestly, no, (I don’t have concerns about LPCs), not in those terms. I would flip it over to a more positive way of looking at it which is six or seven years ago, there were an awful lot more smaller LPCs, an awful lot more cottage industries, one-man bands.
“Actually, there’s been a quite a journey in LPCs over the last six or seven years and you can see the professionalisation of LPCs as you see the larger groups such as community pharmacy Greater Manchester, community pharmacy West Yorkshire, community pharmacy Sussex and Surrey, community pharmacy Thames Valley.
“But even where there hasn’t been amalgamations, there’s been federations and even where there hasn’t been federations, there’s an awful lot more partnership working.
“So in the South West, you’ve got big chunks, Cornwall, Devon, Somerset, Avon, and you couldn’t have one LPC covering that because the mileage would kill you. In large rural geography, you’ve got to have some sort of localisation.
“But we have worked together like never before and that has helped us be more effective and we share resource and we outsource functional.
“So if somebody is really good at X, the LPC that’s really good at X leads on X. So I think there’s a really positive journey developed.”
Actively campaigning for PCN engagement fund
Progression within healthcare goes hand in hand with funding and there have been concerns that community pharmacists will struggle to devote time to PCN work streams without funds to cover their staff backfill costs.
Michael reveals he has been “actively campaigning” for LPCs “to have a PCN engagement fund.” Alastair Buxton said on July 22, the day the five-year settlement was announced, that he hoped the details would be finalised “in the next week or so.” Yet, at the time of going to press, there had been no word.
“I got lucky in Somerset. Sometimes you make your own luck. My CCG decided to invest in community pharmacy and I put together a local business case for what I would need if I was going to optimise integration and engagement with PCNs,” Michael says.
“It’s not a magic formula. One PCN needs a lead and that lead probably needs to do something every month and the backfill I then is 12 days times £250 or £300. If you give me £3,000 to £3,500 times my 13 PCNs, I will then deliver a PCN engagement plan with pharmacy absolutely at the front edge of the PCN development.
“A PCN fund was given to me, so I got £39,000 from my CCG’s primary care team in Somerset to specifically enable our PCN engagement plan. Weeks ago we had already put in our champions, so we now have a lead for each of our primary care networks.
“So when it comes to claiming the pharmacy quality scheme (PQS) money around PNC engagement, in Somerset, here’s the lead, it’s all set up, we’ve already had It agreed with the CCG, we’ve connected with the clinical director on your behalf, all the mechanics for that PQS in Somerset are already set up.
“Funding was made as a good investment by the CCG to enable that because they see the role of community pharmacy being vital. I’m not unique and I wouldn’t say that in the four-box grid, the herd are there.
“I would say mainly people are saying ‘I can’t get local money, PSNC, can you get national money?’”
North East London LPC secretary Hemant Patel said £3 million a year will need to be found collectively for all LPCs. Michael’s assessment is not a million miles away.
“The trouble is if you multiply it by 1,259 PCNs at £3,000 each, you need £3.9 million. So it’s an ask of £3.9 million at a government level if you wanted to mimic what Somerset have done across the lot.”
He adds: “On a brighter note, wrapped up in the pharmacy quality scheme, there is £900 per contractor for saying ‘I am in a PCN and we have enabled a local structure to connect to PCNs. That’s £900,” Michael says.
“That is worth…well £900 multiplied by 105 pharmacies, so that £100,000 in essence that my contractors are getting locally for saying ‘we’ll come on the journey.’
“Now, I’m not saying the £900 per contractor should then be churned back into paying into all the PCN engagement activity. I think there should be additional money on top of that. And my CCG has agreed with me which is why it’s funded it.”
Despite some dissatisfaction over the revenue-generating potential of the community pharmacist consultation service (CPCS), he believes it provides opportunities for pharmacies to make money.
“We get CPCS lined up in Somerset and do the maths on it. A hundred contractors, (say) it does 10 a week. Multiply that by £14 per transaction over 52 weeks, all of sudden there’s £250,000 worth of new revenue that my contractors are getting.
“The seven directed enhanced service schemes coming down to them, that is a great opportunity as well. That will attract new funding. That is new services with new funding, £4.5 billion or whatever the figure is, that money will fund new delivery of new ways of working and models of care.
“If you take the health budget at a total, what is it, £135 billion, £155 billion, it seems to be on a trajectory up in terms of the billions we’re spending as a nation, we’re £2.6 billion or £2.58 billion in pharmacy.
“That leaves £130 billion left that’s still going into other chunks of healthcare. Could we do a small bit of that? Could we get access to the rest of that funding?”
Primary care network facilitator
He is adamant that LPCs should co-ordinate community pharmacists’ engagement with PCNs but that the engagement itself should be carried out by what he describes as community pharmacy networks rather than individual pharmacists.
“The term I’d coin is CPN, community pharmacy network, that kind of co-terminus. Yeah, I think so. However, relationships are like a matrix. So if I’m in pharmacy A and I’m right next to GP surgery A, of course I’ve got a direct relationship with that GP surgery.
“If I’m behaving and working with that GP surgery beautifully and we’re beginning to build that one-to-one trust, that’s a real strand of trust. It’s how do we weave the individual strands between individual pharmacies and GPs, how do we weave that into a new, stronger thread?
“That is why in Somerset, we’ve appointed a facilitator for each PCN, for each community pharmacy network, because we think that if people are jockeying for primacy or trying to do something on top of the other contractors, that won’t help.
“You’ve got the PCN construct with the clinical director and there’s obviously a support team around them. Clinical directors won’t want to hear from 10 individual pharmacies. They will want to know pharmacies on their patch are part of team pharmacy and it’s part of team primary care.
“That’s why (I’ve) said… don’t go jockeying for one-to-one relationships here, don’t everybody start petitioning the clinical directors and start petitioning them ‘ooh, ooh ooh, choose me.’
“But that’s not to say individual pharmacy teams won’t be positively developing their relations with individual general practice teams. And not all those relationships are beautiful.
“Some are great, some are alright but some, historically, have not been as good as they could or should be.”
Robust network of provider companies
Michael suggests GP pharmacists are “one of the greatest enablers” in smoothing community pharmacists’ transition into PCNs but agrees with Hemant’s view that independents need “influencing, negotiating and leadership skills” training if they are to make an impact.
“We need to be better at that whole change management cycle stuff and negotiation skills and co-production. That is true. We need to get way sharper at that,” Michael says.
“As well as LPCs being better at that, individuals on the ground need to be better at that. But we also need a more robust network of provider companies as servants of LPCs.
“The PSNC is now on a very driven mission to establish a robust network of provider companies that can act as really good vehicles for contracting and negotiation.
“I believe LPCs can be supported to be at the top of their game and move ahead and I believe provider companies need be developed as a second wing of that.”