Do independents have the skills to succeed in primary care networks, asks Reena Barai. The National Pharmacy Association board member talks to Neil Trainis...
It has been an interesting last couple of years for Reena Barai. It began with her securing election to the National Pharmacy Association (NPA) board, the first Asian female pharmacy owner to do so. In January she was appointed community pharmacy lead for Cheam and South Sutton primary care network (PCN).
It is an exciting or daunting time for her profession, depending on which way you look at it. The healthcare landscape has changed dramatically. At one time everything in the NHS swirled around general practice and hospitals.
Now it is all about local community-based healthcare and prevention and, for the first time in a very long time, community pharmacy is being taken seriously as a frontline player in the health system.
Reena, who has run S.G. Barai Pharmacy in Sutton for 16 years, is well aware of the challenges facing her in her new role. We sit in a tidy consultation room in her pharmacy where she ponders her reasons for becoming a pharmacy PCN lead.
She took it on, she says, simply because she felt she could make a difference.
“I have spent 16 years working here, building really good relationships with my local GP practices and I felt I had good relationships with the contractors around me as well that I could support the contractors to work with the GPs.
“I felt I was a candidate for that. Also, being the clinical commissioning group locality lead for the last 10 years, I’ve got to know the CCG and I’ve got to know the characters who are moving into PCN land. I think that really helps.
“My difficulty is where I am, my pharmacy is in the middle of three different PCNs, so I had to make a tough decision as to which PCN I’m most aligned to.
“I looked at the GPs I know well, the ones I’ve got good working relationships with and my script volume, where I get more script volume from. So I’m the lead for one and in the footprint for two others. I’m the lead for Cheam and South Sutton.”
She reveals she has been “to a couple of meetings that have been really positive.” Not only does she insist that GPs are very keen to work with community pharmacists in her area but independent pharmacists and multiples are happy to collaborate with one another.
“The GPs have been really receptive, they’ve said they really want to work with us. I’ve got a group of the pharmacists together, we’ve had a good chat and we’re on email together and they’re all really keen to work together. It’s independents, multiples, supermarkets.
“It’s really interesting to see how they are breaking down some barriers within pharmacy, working together is actually quite positive.”
It seems there has been progress in this part of south London in softening the overpowering human instinct to protect one’s own business and pecuniary interests at all costs, yet there are still barriers for independents to overcome.
“We can do the engaging and going to meetings but how do we tell a PCN that we would like to do the blood pressure checks for all your patients within your primary care network?” Reena says.
“To do that, PCNs aren’t commissioners. The commissioning structure still sits above but the PCN may make the decisions about what services are needed locally.
“So the hurdles may be who does what and why and who has the financial purse strings, who makes the decisions. I’m still struggling with understanding the geography of that. I think all of us are struggling with that.”
Can independents write compelling business cases?
Independents might be tempted to think that, as far as PCNs are concerned, it is relatively early days and there is still plenty of time to make an impact. Reena, though, does not subscribe to that view.
She questions whether independents possess the skills needed to get involved with PCNs, including putting their case forward powerfully by writing compelling business cases.
“Well, it’s been a year since they’ve been in place. We’ve been asked to engage over this year and in the last six months.
“I’m thinking we’ll have to make business cases that we’ll have to take somewhere. Are community pharmacists au fait with writing business cases? Are we able to do those sort of things or is that where the LPC steps in and helps us?”
It is one thing to put aside competitive tensions and work with the multiple down the road but Reena says it might not be easy for an independent to join forces with another independent in the same vicinity.
“I think there’s a massive learning need for those primary care network roles in leadership, understanding how to inspire a shared purpose with your fellow contractors,” she says, “because some of them may be your competitors and you have to rise above your competition with that contractor and work collaboratively. It’s not easy for everyone to do.
“The second thing is people need to speak NHS. Do people know how to talk to their GP? Do they know how to use NHS language that GPs understand? We’re good at talking to each other as community pharmacists but do they know how to speak to primary care people?
“Those are two skills. And then there are business cases, commissioning landscape, all of those things are massive learning needs for community pharmacy.
“I think there are people who are trying to organise training and support for PCN leads. I read something in the PSNC letter that there’s going to be support towards that.
“What that looks like will be interesting but I think we need more support.”
Community pharmacists have been told their destiny is in their own hands yet much of what has been mapped out for them feels uncertain.
Take LPCs. They are critically important vehicles in smoothing pharmacists’ integration into PCNs but what if the number of LPCs across England is reduced, something the multiples desire judging by their response to an ongoing review? Reena politely declines to comment on the review because, as she reveals, she is on the “steering committee.”
Centralised funding/training for PCN leads would be useful
Then there is funding to facilitate pharmacists’ integration into PCNs. On the day it announced the five-year community pharmacy contractual framework (CPCF) last year, the PSNC said it would secure a PCN fund to support training and increased capacity for pharmacists to get involved.
“It hasn’t materialised as yet,” Reena suggests, “but it’s gone as part of the quality payment scheme, so if you’re a PCN lead you get more points. It’s not going to cover much to be honest.
“I can go out and do what I feel I need to learn but I think we should all be doing it together so that when we turn up to our PCN meetings, we’re speaking the same language otherwise you’re going to get a bit of a postcode lottery where one PCN is great and engages a pharmacy and the other doesn’t and I’m worried about that.
“So I think some centralised funding and training for PCN leads would be really useful.
“I don’t know if the PSNC have come up short. We just don’t know. There is some funding but we just don’t know what it’s going towards.”
She is asked if the second year terms of the CPCF, including a temporary uplift in transitional payments and the introduction of a discharge medicines service, is reason for optimism.
“When I first read the letter that came out I thought ‘what’s new in here?’ And there were a couple of new things that I didn’t expect to see like the travel vaccinations. That I’d never heard mooted around, so that was quite interesting.
“I actually appreciated the transparency of the PSNC letting us know as soon as possible even though there was no detail. People said it was annoying there was no detail but I kind of feel we’ve always had a go before about not having information and now we’re getting it in dribs and drabs which I know is not easy either but at least we’re getting something. It does feel like there’s good communication.
“The discharge medication service, we thought it was going to be called a medicines reconciliation service but it’s been called a discharge medication service but I really want to know more about it. I’m desperate to know more about it but there’s no detail.
“I’m quite keen to get going. We are where we are. That’s what I’ve had to accept with the PSNC. I don’t think it’s their fault. If I read between the lines, I don’t think they’re hiding stuff from us.
“I think it’s really that they don’t know and they’re trying to be as transparent as they can be so we can have at least an inkling of what’s going on.
“We’ll be told about a service about a month before and we’ll have to get our act together like we always do.”
The community pharmacist consultation service (CPCS) has not been a resounding success for Reena. “I’ve only had one referral since October,” she reveals.
She goes on. “We had more NUMSAS (NHS urgent medicine supply advanced service) referrals. Maybe because more pharmacists are doing it, people are going to other pharmacies maybe if they are getting the referrals.
“Or maybe our 111 centre isn’t sending out the right people towards pharmacy possibly. I’m not sure. I have a feeling it’s all down to your local 111 and how well they’ve been trained and how well they are sending patients out to pharmacies. I don’t know the stats locally.
“The discharge medication service, I know we could well with here. We’ve got a hospital down the road, we’ve got a lot of patients with blister packs who are in and out of hospital, so I know we do this service anyway. It would be great to get paid for it. Some recognition for it would be great so I’m excited about that.” She says the CPCS has left her feeling “upset.”
“I’m upset about that because I got myself ready. I’ve got my stethoscopes and all my bits ready to all the stuff and I’ve had one patient.
“What I’m excited and geared up for is the GP CPCS where GP surgeries are referring. I think that will be the way forward. We’re told October, so that I’m excited about.”
Hub and spoke difficulties for independents
Reena is not particularly excited about the idea of hub and spoke being rolled out to independents. Research published by the NPA claimed hub and spoke is not necessarily cost-effective or safe.
On patient safety, the study said “more rigorous independent research is required.” On economic benefits, it said there needed to be “evidenced cost benefit cases.” Reena agrees with the study’s findings.
“There is no evidence that it will save money to anybody. In theory, it feels like it will be an efficiency but in reality, we’ve got no proof to show that.
“I can understand how somebody in the government would think that would make sense, that it would be a cheaper way of supplying medicines. I don’t actually think it would be.
“Before anybody goes ahead and does it, we’d need the economic analysis on it because somebody like myself will be the last person to get on with hub and spoke. It will be the big multiples who get on with that.
“As an independent, I’ll be at the bottom of the line but I don’t want to miss something if there’s an opportunity. I want somebody to be brave and do some research into the economic evaluation of it.
“How it would work as an independent is really difficult. I’m struggling with the visualisation of it unless we do it with a wholesaler as an integrated thing.
“I feel like it’s geared for multiples but I’m keen to see how independents can benefit from it if there is a benefit. So how do independents tap into the CCA (Company Chemists Association) model where they would easily be able to do hub and spoke? For us it would be harder.”
One strong proponent of hub and spoke has been the chief pharmaceutical officer Keith Ridge.
“Yes, it’s interesting how he’s pushed this forward,” Reena says, offering a smile. She does not, however, agree that Ridge is not a fan of community pharmacy.
“I think that’s an unfair assessment. When you’ve got a job to do, you’re going to make friends and you’re going to make enemies,” she says.
“Being a chief pharmaceutical officer is a tough job and he was probably put under pressure to make efficiency cuts and saw community pharmacy as a place to do those.
“I’ve never met him if I’m honest so I can’t tell you if he’s a nice guy or not. I just think it’s a hard job to do and he probably does the best job he can.
“Does he know what it’s like to be in a community pharmacy six days a week, run it, does he understand what it is I do every day? He’s got a job to do and he’s doing it.
"My job is to show him as an outsider that community pharmacy is not always the way it is portrayed.”