Covid almost killed Hemant Patel but he recovered and is now a clinical lead at an integrated care system where his focus is health inequalities and population health management. Neil Trainis caught up with him...

Hemant Patel has left community pharmacy but community pharmacy hasn’t left him. It’s in his DNA. Pharmacy courses through his veins and that’s not surprising given he spent more than four decades in the profession, during which time he had leading roles at the Royal Pharmaceutical Society of Great Britain, National Pharmacy Association and Community Pharmacy England (then PSNC) to name a few.

The idea that he can detach himself completely from community pharmacy appears to be futile and as we talk about his new job, which he says “has little or nothing to do with pharmacy but it is probably the most fulfilling role” he’s ever had, he acknowledges with faint amusement that he runs the risk of inadvertently referring to community pharmacy as “we” during this interview.

Naturally, though, he is very keen to talk about his new two-year post as clinical lead, health inequalities and population health management, at Mid and South Essex Integrated Care System. He also reveals he’s been appointed vice-chair of Southend Health and Well-being Board. He describes his ICS role as “really interesting” and talks about it with palpable excitement because he thinks it will give him the chance to make a bigger impact when it comes to securing social justice and health equality for people on the periphery of society than he had during all those years he spent in pharmacy.

If we were to summarise without over-simplifying Hemant’s new role, it could be said that he helps to design and create health services that reach people who have found it hard to access quality healthcare, such as drug addicts, the homeless, the mentally ill, the unemployed and people from ethnic minority backgrounds. He says he’s always been something of a social crusader.

“What is happening at the present time is the NHS is going through the most radical change in its history. There used to be a medical model where if you fell ill, the doctor or somebody will intervene and try and fix you. The NHS has now decided it’s time we invested in preventing people from falling ill,” he says.

“The volume of treatment was going up all the time and the cost of service was rising all the time. The new approach, the social model of health, means you take an interest in people and you try and help them not get sick, and this social model is being introduced within the NHS.”

This localised, community-based approach to preventative care, he says, involves identifying “the social determinants of health” including, not only lifestyle, but schooling, income, even genes.

“All of that plays a part in determining how healthy you are. And so, it’s a much broader consideration rather than symptoms-treatment, symptoms-treatment.”

Reduce health inequalities in all populations

He explains his role as clinical lead splits into two. One is to try and reduce health inequalities in all populations. The second is to use a technique known as population health management “which means you collaborate with all organisations that are contributing to the wider determinants of health.”

Hemant elaborates on the second approach. “This sphere of influence has to be quite wide which is very different from knowing about medicines and just focusing on medicines and outcomes. The role is to work collaboratively with a whole range of stakeholders. Apart from primary care and community pharmacy within that, we’ve got hospitals, local authorities, the voluntary sector, everybody plays a part in devising a care pathway.

“We want to design care pathways which are effective and efficient. What does that mean? It means patients have good access to preventative services. The third thing is we are looking at a positive change in people’s health beliefs because by changing people’s health beliefs, you bring about a different outcome. It’s a multi-party organisation looking at populations and trying to make sure no-one is left without effective healthcare. And there’s a role for patients too in the system because you cannot enforce lifestyle change on somebody, so we involve the patients in that as well.”

The idea that patients should be placed at the heart of their own healthcare didn’t materialise with the creation of ICSs, of course. The self-care movement in the UK has trumpeted it for many years but it feels like we might be on the verge of something more substantial with ICSs. Hemant is more than happy to be doing his bit to help develop and cultivate the transformative power of health education and support the 1.2 million residents across his ICS’s region and people who have been unable to access services so they can lead healthier lives. It’s as if Hemant is fulfilling a life-long ambition for social justice.

“In terms of my key deliverables is working with others and looking at holistic care, so prevention, treatment, everything. It is also about empowering patients to make decisions for themselves.

“For example, encouraging people to take physical activity, looking at their diet. How do we encourage them to take control of their own lives rather than depending on others? Then there’s leadership and influencing skills.

“I always felt I could lead and, in some way, I’m doing something which I’ve practiced for a long time.”

He concedes his new role is “a massive challenge because there are so many different players” but there is no doubt he relishes taking it on. Yet, it’s also a “massive challenge” because of all the other pieces that need to fall into place. Analysing and interpreting “a huge amount of data, about places, about people, about outcomes,” for example. As he points out, population health management must be evidence-based and data is imperative if you’re devising a strategy.

“And there’s a really important thing which is now carefully considered by the ICSs and that is support for equality, equity, diversity and inclusion. Basically, that’s my job. It’s a part-time job but it’s an important leadership within that ICS.”

At the moment, he works one day a week in the role which urges him to focus on NHS England’s Core20PLUS5 initiative. NHSE says it informs “action to reduce healthcare inequalities at both national and system level” in the most deprived 20 per cent of the nation’s population as identified by the national Index of Multiple Deprivation. The five clinical areas NHSE believes requires “accelerated improvement” as part of Core20PLUS5 are maternity, severe mental illness, chronic respiratory disease, early cancer diagnosis and hypertension case-finding.

Four decades in pharmacy, 26 years of which he spent as secretary of North-East London Local Pharmaceutical Committee before he stepped down in 2021, probably entitled Hemant to a break. Not that he subscribes to that view, such is his appetite to work at 69. The magnetic pull of his ICS role was social justice, a concept, he insists, that has gripped him since he was a teenager growing up in Dagenham which has had its fair share of poverty and deprivation. The role, he suggests, is “probably more challenging” than he imagined it would be but he insists “that’s the excitement bit as well.”

He reveals he was encouraged to apply for it “by people within the wider healthcare system” who knew about his interest in health inequalities as well as “an old contact” who told him to look at the opportunity.

A brush with death

But what is extraordinary is he took up the role despite having almost lost his life to Covid. A brush with death might have persuaded others to retire for good. Not Hemant, who recounts his traumatic experience vividly.

“I nearly died with Covid. My breathing was so bad, I could not even finish a sentence. The paramedics came and they wanted to take me to the hospital and I said ‘no, if I’m going to die, I’m going to die in my bed.’ I was not even able to walk from my bed to the loo without assistance. By the time I got there, I would need to sit down on the toilet seat and brush my teeth, it was that bad.”

He makes it sound as though his inability to work, his boredom, was as distressing as the impact the deadly virus was having on his body as he gasped for each breath and battled exhaustion.

“I got three Covid infections and long Covid and for 18 months, I was in a very unhappy place where my mind was racing with ideas and wanting to do things but physically, I was unable to do that work at all. I was getting up as if I was drunk. I had fogginess in my head and by lunchtime, I was so exhausted, I’d go back to sleep.

“But gradually, things started to happen. I started walking and things started to improve. Then, it was a question of being bored and I was talking to people and I was still writing. I like writing, it helps me get my ideas out. Then one day, a colleague said ‘look, it seems like you’re on your feet again. There is this opportunity and looking at the job description, it is ideal for you. Look at it.’

“Even before I finished reading the job description, I’d made up my mind that I was going to apply because this was something that, from the bottom of my heart, I could give everything. Social justice is part of me. I want to see equality. I want to see fairness. We are the sixth biggest economy in the world.”

Hemant is angered by the food, drinks and pharmaceutical industries which he says have combined to overwhelm the NHS. “Just think about it. You’ve got a system which is not in balance. The more we spend, the more the drugs and alcohol and food industry spends. So, I thought ‘here is my chance to play a role in changing lives.’”

Marrying health and social care has been the political Holy Grail for a long time. NHS leaders and commentators have said that if you can pull that off, you’ve cracked it. The idea that as a community pharmacist, Hemant wasn’t able to do all the exciting social work that he’ll be doing at the ICS is intriguing. It makes you wonder what barriers, if any, he encountered in pharmacy.

“I did some of that good work but not as a commissioner but as a provider. I’ll give you two examples. Smoking is a big killer in our country. Smoking cessation is a way to help people extend their lives. That’s one example.

“Vaccinations is another example where we vaccinated people who were, quite frankly, not interested in any vaccination. So, we got them engaged. I did some work, I talked about it, I wrote about it.

“Here is my opportunity to work with the great big system and influence and make things happen. I can’t tell you how excited I am because I’ll be looking at projects for young children, teenagers, adults and the elderly. I’m not a single, superhuman who’s going to be doing all of this but I will have an influential role as a clinical leader to advise on what is going so it leads to a good outcome.”

There is cross-party support for ICSs. In March this year, the chair of the health and social care committee Steve Brine said its inquiry on the autonomy and accountability of Integrated Care Systems “found genuine enthusiasm for their potential to make a real change, not only in how health and social care is delivered but in prioritising the needs of local populations and preventing ill-health.” It feels like community pharmacy teams across England will be given greater scope to make an impact on community health and prevention than they were in the last NHS reorganisation during the Lansley years.

After all, we should hold NHSE to its word that it wants “pharmacy professionals working in integrated care boards, acute, mental health and community trusts” and community pharmacy and general practice collaborating on ICS work streams – even if NHSE may not have complete operational control of the health service. Remember that in December last year, NHSE chiefs were made to move into the office of health secretary Steve Barclay, allowing him to stroll over to their desks and have his say. When it comes to community pharmacy’s prospects in ICSs, Hemant is circumspect.

“There are two things. Firstly, instead of one NHS, we’ve got 42 systems, so there will be a local focus. While accountability and autonomy is taken very seriously, the resources available to deliver the ambitions of the NHS really need a radical review. In my view, without the resources, we will not be able to deliver the promise of the ICSs.

"People I’ve come across, really talented people, their commitment to their work is truly impressive. They’re highly intellectual but also highly compassionate people. I enjoy working with people with positive attitudes and all those skills. The potential together with the resources is really important.

“Secondly, pharmacy still somehow thinks that central control is important in order to provide services. I think there are people who are wrong in that sense. ICSs are a local system and I see two things happening; one, at least for the time being, the dispensing contract might remain centrally but all non-dispensing activity can easily be commissioned at ICS level.

“When pharmacy has got an ambition to provide knowledge-based services in partnership with others, there’s only one way to achieve that – working through the ICS as a whole. It’s a system with many, many partners.”

Politicians always want to interfere

It’s also worth pointing out that one of the recommendations of Brine’s Committee was for NHSE/DHSC not to interfere in ICSs. If they “are to realise the ambitions that have been set for them and move beyond collaboration towards true integration,” the Committee said, “it is vital that DHSC and NHS England do not dictate how ICSs should deliver those outcomes. NHS England will also need to be conscious of its organisational culture and make concerted efforts to not revert to overly restrictive ways of working.”

Hemant thinks “politicians will always want to interfere” but reserves judgement for now. “I’m slightly more optimistic than I was three years ago that the NHS will be allowed to do what they want to do.”

For community pharmacists, concerns lie closer to home. He says they must understand how the ICS system works and how they can forge relationships, not just with GPs, but with all the players. However, what will become clearer under ICSs, he believes, is the commissioning structure which has been a hotchpotch.

“We had smoking cessation commissioned by the local authority and dispensing commissioned by the NHS at a national level and the flu being commissioned by CCGs but this will all now be brought together in some way,” he says confidently before cautioning that collaborative initiatives must be backed up by money for digital infrastructure.

“Without digital ability, we are not going to see deeper penetration into the communities and integration cannot occur without the digital resources.” And, he adds, “the whole system will have to take account” of artificial intelligence. Maybe we should get ChatGPT to plan out the NHS’s next 30 years.

Words such as ‘collaborate,’ ‘federate’ and ‘integrate’ have been tossed around the healthcare arena in recent years but despite good intentions, the human instinct to make money, to get one over on your rival, threatens to undermine the cosy world of collaboration. GPs’ dirty tactics over flu posters are still fresh in the mind. Hemant is confident ICSs will not be impeded by self-interest.

“We need to go back to a simple question; why did you become a pharmacist, why did you become a doctor, why did you become a nurse? It was to serve the people and help them heal in one way or another. Now, it seems to be that the old system didn’t quite recognise the purpose for which the professions were created. The new system, I think, is much closer to helping people realise the reason they were created as professions and there’ll be new professions created as well in the new system.

“I became a pharmacist to serve local populations and in providing these services, I hope to earn a living which recognises my status and ambitions. There’s a different mentality compared to a trader who places profit before clinical outcomes. The good thing about the new system is there will be transparency and accountability.”

He insists an integrated system will bring with it “joint accountabilities for outcomes.” Different health professionals will have no choice but to collaborate. “In smoking cessation, there’s a scheme that says ‘no quitter, no fee.’ It says ‘yes, you’ve done the work but you haven’t produced an outcome, therefore there is no payment for you.’”

Hemant says ICSs will be immune from the perils of competition if they “design systems that reward collaboration and activity” as they presently do. In her independent review of the progress made by ICSs, former health secretary Patricia Hewitt concluded national contracts, including the GP contract, create a “significant barrier” to local innovation. She warned “contracts with national requirements can have unintended consequences when applied to particular circumstances.” Hemant told this year’s Sigma conference “national contracting is going to die, local commissioning is going to survive and grow.” He tells me “contracts for perpetuity are coming to an end.”

The future, he insists, is “time-limited contracts with review dates and performance measures and it’s a completely different game.” Local collaboration is all the rage.

It’s time for community pharmacy to play the game.

Hemant’s tips for community pharmacies to make an impact with ICSs

• Engage in knowledge exchange and continuous learning with the ICS.
• Establish meaningful proposals with diverse organisations including the volunteer sector.
• Innovate, problem-solve and go to the ICS with solutions.
• Enhance professional development through workshops and training.
• Get support from pharmacy peers, support one another and share evidence-based innovations with other ICSs.

Hemant’s 7 Ds – the aspects of healthcare policy that promote integration in the system

Devolution: The transfer of powers and decision-making responsibilities to regional authorities in the UK, allowing them to have more control over healthcare systems and policies.

Devolvement: The decentralisation of decision-making in healthcare, empowering frontline healthcare professionals and local organisations to shape and improve services.

Digital enablement: The integration of digital technologies in healthcare, enabling providers to enhance service delivery, streamline processes, and improve patient outcomes through digital platforms, telemedicine and health-related apps.

Demarcation: Defining and integrating the roles and responsibilities of different healthcare professionals, ensuring collaboration and effective coordination of care.

Democratisation: Involving patients and the public in decision-making processes, promoting transparency, inclusivity and equitable access to services.

Deprescribing: Reducing or stopping unnecessary or inappropriate medications and optimising medication regimens while reducing adverse effects and improving patient safety.

Diversification: The expansion of healthcare services and roles beyond traditional boundaries.