Dr Richard Vautrey says the CPCS is a mess and insists that ultimatey, it does not matter who sits on integrated care boards. The former chair of the British Medical Association’s GP committee talks to Neil Trainis…

Dr Richard Vautrey pulls no punches and it comes as no surprise. You wouldn’t expect anything less from a man who chaired the British Medical Association’s GP committee for four years during which time he vigorously fought general practice’s corner.

Some notable successes were achieved on his watch. He helped secure £2.8 billion in funding three years ago as part of the five-year GP contract in England and put an end to GPs paying for indemnity costs out of their own pockets.

Not everyone in the media has been convinced by him. In November, the Daily Mail described him as “Mr U-Turn,” claiming he had said at one time that he did not feel comfortable making diagnoses via remote consultations before going on to lead a BMA campaign in favour of them. As we talk remotely over Teams about general practice and pharmacy’s place in an NHS driven by integrated care systems and local collaboration, what becomes clear pretty quickly is he is not shy in expressing a view no matter how strong.

The community pharmacist consultation service is a case in point. Put simply, he does not think it is up to scratch, describing it as “a referral process which adds to the burden of general practice.”

“It isn’t as good as what we had before when we had various minor ailment schemes where we effectively just directed patients to the pharmacy next door or over the road. And that’s what we want,” he says.

“We want to be able to encourage patients to use pharmacy appropriately and identify those patients who would benefit from the services of a pharmacist. But what we’ve got is a system that is more about trying to measure the number of referrals that are made and to make payments to pharmacists rather than supporting that direct engagement between practices and pharmacists.”

Pharmacies have endured their share of frustration with the CPCS. Just 13,000 patients from 280 practices were referred to them through it between October 2020 and May 2021. It seems GPs have been fed up with the bureaucracy that comes with it.

“I think it’s quite simple to resolve but it means then that NHS England and the government wouldn’t get the data that they want in terms of the number of referrals that are made,” Richard says.

“What should happen is that the system should trust practices to make the necessary referrals and should trust pharmacies to do the right thing when patients walk in to use their services. It’s about empowering general practice and pharmacy to work very closely together without adding more burden as part of that transaction process.”

CPCS is “a complex mess”

He is asked if some GPs have reached a point where they cannot be bothered to refer patients through the CPCS because of all the red tape. It is, he insists, a “process that’s proving really quite laborious.”

“It’s just taking time. I was sat with my reception staff (recently) to work through what happens when they receive a call and it’s taking them up to 10 minutes to work through the questions and the form-filling that’s required. We could’ve dealt with that patient in that time.

“At the same time that the patient is being held on the phone, it means other patients are getting irritated because they can’t get through because the reception staff are trying to deal with the particular patient’s problem and direct them to a more suitable service.

“At the same time, it’s taking quite a long time to do that and thereby irritating other patients who can’t get through and, actually, we could’ve dealt with that problem within a matter of minutes. This is part of the problem and it’s an unintended consequence of the process but I think if we had what we used to have which is a pharmacy first scheme, that would be helpful.

“One of the other consequences of (the CPCS) is that when patients are directed to the pharmacist, they don’t necessarily get the free prescription they might have got if they got a prescription. So, for those who have free prescriptions, it is actually then costing the patient whereas under the previous minor ailment scheme we had, there was a whole range of medication that was free to patients. Patients are then coming back to the practice irritated that they’ve all of a sudden got a charge to pay whereas previously they wouldn’t have had.”

Richard describes the CPCS as “a complex mess of prescription arrangements” that sees “some people pay, some people don’t, some people get services free at one point but don’t get them at another point.” He insists the system needs to be reviewed immediately because significant funding for GPs hinges on them engaging with the CPCS.

“From a general practice point of view, the funding that was identified for the GP access and support package, the £250 million, was linked to sign-up to this particular scheme. Practices are expected to sign up to the scheme to access some other money and that’s just one of the many strings attached to the access of this funding which is really desperately needed in practices and yet they’re having to go through this process to access it.”

The health secretary Sajid Javid last year said patients should go directly to pharmacies for their minor ailments without going to a GP in the way they do in Scotland. Richard agrees.

“Yes, I think for appropriate care. As patients become more aware what services pharmacies can offer and more confident they’ll get that service, then they should use the pharmacy. I have full confidence our pharmacy colleagues can deal with many patients, their conditions and problems, in an effective way. But the patient needs to get the same service when they go there, so when they need a prescription, they need to get that free if they’re eligible.

“All of these systems need to be joined up in a much more effective way so wherever a patient presents in the system, they get consistent advice and treatment.”

He insists the BMA is working closely with the PSNC and other pharmacy bodies to generate public awareness of the pharmacy-first message and is adamant there needs to be a move “away from the simplistic and often counterproductive attitude that if you haven’t been seen by a GP, you haven’t had a proper service.”

“Many LMCs work very well with local pharmaceutical committees and try to have common agendas and strategies around that. But it is a consistence of message that needs to be put out and it needs to be seen that it isn’t undermining one service or the other when you’re doing that.

“It takes quite a long time to change a culture that is ingrained in many people’s minds for generations - for a particular problem you go to this particular service, whereas we need to show there’s a breadth to community-based services, and it isn’t just pharmacy this applies to but optometrists and other community services.”

Workforce challenges

Effective collaboration between health professions, of course, depends on a strong workforce. In a letter published in The Times last year, Richard said there was “a major national shortage of GPs” and warned the government to “get a grip of the national GP staffing crisis” by “recruiting new doctors to general practice and retaining the GPs we do have by scrapping unnecessary bureaucracy.”

Community pharmacy too is apparently suffering from a shortage of pharmacists. The former chief pharmaceutical officer for England Keith Ridge told last year’s Clinical Pharmacy Congress that the “osmotic draw” of primary care networks was responsible. Another one of Richard’s successes as the Committee’s chair, depending on how you look at it, has been the recruitment of pharmacists in practices. Some within community pharmacy think that has been a bad thing.

“I think it is a good thing,” Richard says. “It’s something I called for for a number of years, having a pharmacist in every practice. A number of practices were employing pharmacists directly before the primary care network arrangement developed and now with the PCN funding, there is a great emphasis on recruiting pharmacists to work directly within practices and primary care networks.

“I think there’s a lot to be gained from that and pharmacists can really add value to the quality of prescribing, the quality of clinical care being delivered within general practice settings and can also reduce the workload pressures in general practice.” He insists he and others at the BMA are “very conscious of the fact there is a limited resource in terms of the workforce.”

“When this programme was developed sort of three years ago now, it was at a time when we were told there was a surplus of pharmacists, that pharmacy skills were generating more pharmacists than could be employed,” he says.

“Clearly, the workforce hasn’t kept up to pace with that and what we need is a real workforce strategy that is aligned to the needs of the whole system. That’s why the BMA was lobbying for workforce strategies to be part of the health and social care bill so that we can really plan properly as a nation what recruitment we need across the piece. It’s imperative that we get the right level of training in place, whether that be in a general practice employment or a community pharmacy employment. We all need a proper workforce strategy.”

One of community pharmacy’s USPs is its ability to reach people on the periphery of society; drug addicts, the homeless, the unemployed. But if large numbers of pharmacists are diverted to GP practices, surely it will harm community pharmacy’s efforts to reach them. Richard is not impressed with that view.  

“I don’t agree with that. GP practices are part of the community and will reach out to homeless patients and those who have got alcohol and drug addiction problems, those who have got multi-morbidity issues with complex pharmaceutical arrangements. All of that happens in a general practice setting as well.

“What we need to see in future is a much greater collaboration between all healthcare professionals working in community-based settings. Having pharmacists embedded within a practice team brings huge benefits if you get that communication right and starts to break down historical misunderstandings between different professions and, hopefully, leads to a better relationship between general practice and community pharmacy because what I’m finding is if you’ve got the pharmacist in the general practice talking to and engaging with the pharmacist in the community pharmacy, you end up with a much working arrangement.”

He concedes, however, that the GP pharmacist programme “may be playing a role” in the workforce shortage that we are led to believe is blighting community pharmacy.

“We also need to recognise there’s pharmacists going into hospitals, pharmacists going into industries, there’s a whole range of options open to newly qualified pharmacists.”

GPs’ influence on integrated care systems

At the moment there does not appear to be much scope for healthcare professions outside of general practice to make an impact on integrated care systems. At least that was the sentiment the PSNC, along with numerous bodies from other professions, tried to get across last year. The Health and Care Bill, they warned, dictated that each integrated care board (ICB) has a member who will be nominated by general practice “with no (requirement for) insight from any of the other primary care professions.” Is it fair to say ICSs will give GPs too much power?

“The perception of GPs is quite the reverse,” Richard suggests. “They will say that actually, they won’t get enough of a say or involvement in the decision-making of the integrated care board and with only one place on that board for a GP representative or a wider, primary care representative, it’s going to be a very secondary care dominated structure. That’s what their perception will be.

“I think the reality will be demonstrated in how ICSs and ICBs operate. From a primary care, and particularly from a community-based perspective, we need to ensure and encourage and almost direct ICBs to devolve decision-making around community-based services to local communities and place-based settings where all those involved in community-based delivery can have a say in how the funding and how the services are developed within that local area because you can’t do that on a regional basis.

“Sensible ICSs will empower local decision-making and enable the whole range of people involved in that, dentists, optometrists, GPs, district nurses, social care services, voluntary sector, there’s a whole range of stakeholders will want to have a say in how services are developed.”

Richard says the focus should not be on who has a seat on the ICB because “that becomes irrelevant if decisions are made at a local level.”

“What we need to ensure is whoever is on the ICB, their reason d’etre as far as community-based services are concerned is to ensure most of the decisions are made elsewhere and made in the local community,” he insists.

So the PSNC et al failed to see the bigger picture? “Well no, I think it’s understandable. Everybody will want their particular seat on a board and that’s absolutely understandable and the BMA has been lobbying in a similar way around that. But the reality is for a board to be effective, you can’t have a hundred people suddenly sat around a board. It has to be, by its nature, a limited number of people.

“Where I think we need to look wider is to the partnership arrangements that will operate within an ICS structure. It’s the partnership where you can have a much greater number of people involved including local government, voluntary sector, pharmacists, optometrists, dentists, GPs, community-based services. They can play a role in setting the overall strategy of a board.”

Image: British Medical Association.