Self care is a work-in-progress but for the Proprietary Association of Great Britain, the challenge is to ensure it remains relevant in years to come, says Neil Lister. Its president talks to Neil Trainis…
Neil Lister gives the distinct impression he is never satisfied.
“I think there’s always going to be more work to do on self care because it’s one of those things, as a vision, where people take responsibility for themselves, they educate themselves, they engage more with the pharmacies,” the president of the Proprietary Association of Great Britain (PAGB) says enthusiastically in a tidy office in the London headquarters of the trade association for manufacturers of branded over-the-counter medicines.
“You can never say we’ve done that. There’s always going to be more to go on that.”
Self care as a concept has been around for quite a long time and the PAGB, celebrating its centenary this year, has been at the heart of it. Putting people in control of their own healthcare and empowering them to achieve good health has for years been held up as a powerful way to take the pressure off GPs and other parts of a creaking NHS.
Neil ponders what place self care finds itself in now and how community pharmacists, through individualised support and guidance of the options, can continue to put the public in the driving seat when it comes to their health as opposed to a dictatorial nanny state approach where individuals are told what to do.
“When you look back, the PAGB has been linked with self care since we think about 1972 where the NHS had its first forum on self care and it was sponsored by the PAGB,” he says.
“We think the PAGB takes some credit for the vernacular of self care now being in our common parlance because self care has gone beyond just healthcare authorities now. People understand more about self care.
Almost from the common vernacular of the population, it’s starting to get momentum. In relation to where we are now and where it’s to go, I think we’ve come a long way.
“I think the government’s 10-year plan delivers some way towards that as well but we think there’s some more opportunities to come. The 10-year plan doesn’t actually talk around some of the things around self care like it should do but we think there’s a big opportunity within the implementation plan and that’s where we can make a real difference.
“What the 10-year plan does talk around is prevention and some other areas, cost-savings, which we think work really well to the self care agenda.
“But our aim is now to really imbed within the implantation plan and 10-year plan some things we think are really important. The PAGB have produced a white paper on self care and what that looks like going forward and there are some key elements there which we’re hoping the government will take into consideration and start implementing.”
It was, nonetheless, disappointing that the vaunted long-term plan did not set out much of a role for self care. Indeed, shortly after its publication, the PAGB said the NHS had “missed an opportunity by not making self care a central part of its plans.” Neil is philosophical.
“I’m always an optimist and I think from where we’ve come from…I mean the NHS works slowly, any government body works slowly, so I think we’ve come a long way.
“In the last 10 years, the Self Care Forum and Self Care Week has really embedded the stuff around looking after yourself better at winter and the government campaigns around that. So there’s stuff happening.
“In the 10-year plan, would we have liked there to have been more prescriptive stuff around self care? Yes, we would’ve done. What we’re hoping is, around the implementation plan, we can still do that.
“We met (last month) with Baroness Blackwood, the minister of health, and we engaged on these points, and we’ve got a lot of traction on some of the areas we think are important around self care which we hope will be implemented by the implementation plan.
“Those broadly are, one, the ability of pharmacists to access and write on patient records. Just think about all the enablement that would deliver. If pharmacists can do that, from making MURs better to making medicines better for patients, that would make such as difference.
“We are lobbying heavily for that because we think it’s the right thing to do and it’s long overdue.”
He says the PAGB has calculated the NHS could save £1.5 billion by “implementing some of the proposals around self care.”
“I think it’s a very underestimated amount there but, broadly, £1.5 billion we’ve articulated with the right sources. That includes the patient record stuff and a national self care agenda all year round, it includes having someone responsible in the NHS for self care because the way the NHS works, the different public healthcare bodies work vertically but they are not very good together horizontally about linking things together.
“We think there needs to be a champion for self care overall amongst that. But in the white paper that the PAGB produced, there are four or five major points which, costed out, we believe will save £1.5 billion for the NHS and by doing that, elevate the role for the pharmacist, drive footfall into their stores and drive more conversations into the pharmacy.
“For example, (NHS) 111 we think should be more geared towards going back to pharmacists and being directed to pharmacists. We think pharmacists should have more ability to make referrals, not just to GPs, but to other healthcare providers as well.
“Everything we want to do basically is put the community pharmacist much more at the centre of the conversation to give people a reason to go into their stores and a reason to repurchase.”
Talk of self care, pharmacist-patient conversations and OTC purchases leads Neil to explore what he describes as “green prescriptions” which were introduced into the German health system around 20 years ago and have helped not only drive OTC sales but direct people into pharmacies.
“Rather than prescribing something, doctors can give a recommendation for an OTC that drives the patient into the pharmacy to go and buy that. I think the stats (show that) when people do that, 85% of the next time when they get the same ailment, they’ll go and see the pharmacist first rather than the doctor.
“If we really want to take the burden off the NHS, doctors and A&E, these are the things that will make a huge difference.”
Last year the PAGB proposed recommendation prescriptions allowing GPs to write details of a minor illness, any self care advice and information about OTC medicines they recommend the patient purchases from a pharmacy. It was a recommendation that suddenly went quiet.
“What’s interesting is we think the desired outcome is the right thing, that a conversation with GPs will drive more people into pharmacies, to make recommendations and take products from there.
“What’s happened is there has been, especially across England, a reduction in ability to prescribe OTC medicines but there hasn’t been a link-up to drive people to the pharmacy at the same point.
“So there’s elements of cost-saving that have been put into place but we think there’s further to go to drive that conversation to get people into pharmacy.
“We saw a stat earlier (revealing) there has been some savings for the NHS on this. I think it’s about £25 million in the last year in England. They forecast a hundred million or so, so it’s lower than they anticipated.
“What we’re really passionate about is not just that ‘you can’t get it here” because there’s that follow-up conversation about where you can get stuff. So we think there’s further to go on that.
“Do we wish it was better than it is? Yes we do. Has it made some traction? Yes it has. But we haven’t seen that pull-through that says ‘if doctors are no longer doing X, what’s that push to get people to have a better conversation with a pharmacist?’
“We all have a responsibility for that. Pharmacists have a responsibility through their training and through the services they offer to say ‘we do these things too,’ the doctors have the push responsibility to say ‘actually, go and see your pharmacist about things’ and we as an industry need to inform people there’s services and things available in pharmacies without having to go and see your GP.”
Yet it still feels like the self care message has not penetrated sufficiently. According to the Self Care Forum, there are 57 million GP consultations a year for minor ailments costing the NHS £2 billion and taking up on average an hour a day for every GP.
“What we’re trying to do is get to a position where we get people thinking about healthy living, start taking interventions earlier and changing the way people have been trained to do things. That will take a long time,” Neil says.
“The very fact that you’ve got that data and the fact that the Self Care Forum exists and is talking about that means we are getting traction. At a recent meeting we had with the Self Care Forum, one of the PAGB board meetings, we had a representative from Bracknell Forest’s director of public health talking about the way they are saving money in their local authority and how they are helping drive people through better self care into pharmacies by adopting some of the stuff from the Self Care Forum. So I think it’s getting traction.
“Would I like it to be more national traction and give more momentum? Yes I would. Do I think it’s further to go on the 10-year plan? Am I disappointed there’s not more on there? Yes I am. Equally, I recognise how the system works.
“It’s about getting the right message and continuing that message year after year and we are getting traction. Sometimes it doesn’t feel like that because we haven’t had that big breakthrough on a national scale but I think it will come.”
Insisting “there are lots of examples where the PAGB has punched above its weight in getting things done over the years,” he says the organisation is continuing to lobby for all pharmacies in England to have read-write access to the summary care record.
The PAGB also recently called on the government to make self care a mandatory part of the national curriculum for children in England.
Neil is encouraged by the progress self care has made. He is irked at the idea that NHS England (NHSE) might consider some OTC products as high cost, low value having released guidance for clinical commissioning groups on 35 conditions for which OTC items should not be routinely prescribed.
In that guidance NHSE described vitamins, minerals and probiotics as “items of limited clinical effectiveness.”
“The products are highly efficacious and if it means you can actually get up and go to work and do your job or take your kids to school and get on with your daily life, I think that’s really high value,” Neil says.
“They might be low cost because they’re actually very cheap and affordable. To the consumer or patient, they are high value. Minor ailments, cold and flu or headaches or anything like that, if you ask somebody suffering with those things, there’s a really high value need for it.
“And the ability to be able to go to a drugs store, independent pharmacist or grocers and buy these things, it’s so liberating versus trying to get a GP appointment or, as a lot of people do nowadays, go to A&E.
“I don’t know if you saw a news story the other day about one of the districts in London where they have these perpetual users of A&E that will be visiting it something like 300 days of the year.
“So they realise now that actually getting help to these people trying to live their lives a bit better is going to save A&E massive costs. I hadn’t heard low value…but I take exception to that because I think OTC is very far from that.”
Yet it appears NHSE’s cost-cutting exercise fell short. The minister with responsibility for pharmacy Seema Kennedy told parliament last month that it cut spending on prescriptions for OTC medicines by £25.9 million to January 2019 despite promising up to £100 million in savings. Neil is asked if he thinks that £100 million was unrealistic.
“Not at all. There’s much bigger savings for the NHS if they embrace self care in the right way. The reason it’s only £25.9 million I think is largely because GPs can still prescribe OTC medicines if they want to.
“Saying they can’t any more if they’ve been doing it for five, 10, 15, 20 years, the reality of that is they’re not going to suddenly overnight stop doing something they’ve done for many years.
“As I understand it, there’s only certain areas in England where GPs don’t get access to prescribe OTC medicines any more. The vast majority can still do that. So by saying ‘don’t do that any more,’ it’s going to take a long time for that to emerge.”
Neil offers a smile when asked what his goals are during the remainder of his presidency of the PAGB.
“We are 100 years old this year. On June 17 when we have our big gala dinner is 100 years to the day the PAGB was founded by a bunch of forward-looking gentlemen who all met in a hotel (Cannon Street Hotel) in London which has since burnt down (during the Blitz).
“Part of the work we’ve done for the 100 years is look through the archives and it’s phenomenal to see what the PAGB has done over that time – 1936, the world’s first self-regulated advertising code in any industry was created by the PAGB.
“It was the industry saying ‘you don’t need to regulate on this because we understand our role and we’ll do this ourselves.’ The fact they’ve done that so robustly and that the PAGB set up the right values means it’s been around for a hundred years.
“As part of the hundred years, one of the things we’ve been doing is looking at the next five years. We can’t look forward at the next hundred years because we don’t know what’s going to happen. We’ll all be superseded by robots or something like that but we are looking at the next five years.
“One of the big things we need to anticipate so we’re going to be relevant, and self care is at the heart of that, is the next big milestones in regulation, regulation of the internet.
“We don’t have control of our borders when it comes to the internet. Someone can launch a product in America that someone can get hold of in the UK and how do you regulate that? How do you make sure everyone is working from the same level playing field?
“Environmental challenges are a big one for us as well. If you think about plastics and environmental things, that’s a big opportunity for us as an industry but we’ve got to marry the environmental needs with the regulatory needs around medicines and packaging.”