Nick Hunter wants the government and NHS England to make concessions as well as address the problem of concessions. Community Pharmacy Nottinghamshire’s chief officer talks to Neil Trainis…

A famous poet once suggested that if you can keep your head when all about you are losing theirs, you might just come out the other side unscathed. Or something like that. Which brings us to Nick Hunter.

Community Pharmacy Nottinghamshire’s chief officer for the last 13 years is calmly spoken and measured as he assesses community pharmacy’s predicament and prospects in an NHS that is still getting to grips with an integrated, collaborative, community-based, prevention-of-disease-focused healthcare revolution. If ‘revolution’ isn’t overstating the Conservatives’ latest NHS reorganisation, that is. “It was bad enough when we went from PCTs to CCGs. This seems to be taking way longer,” Nick muses.

He's also very familiar with the local pharmaceutical committee machinery. He was secretary of Rotherham LPC and Doncaster LPC before they merged to become Community Pharmacy South Yorkshire and in July, he became part-time chief officer of Derbyshire LPC.

His experiences in LPCs have given him an acute understanding of what contractors are going through, although he admits his new role is taking a bit of getting used to.

“There’s a lot of stuff to get my head around in Derbyshire. It’s just getting to know people. Some people I knew from old but I haven’t seen them for 15 years. There’s been a lot of meetings, a lot of one-to-one catch-up stuff. And I’m trying to do that on two days a week.”

It might be argued that it’s early days for Nick in Derbyshire LPC terms but it feels a lot fairer to ask him how he assesses his achievements in Nottinghamshire. One local paper enthusiastically reported last month that over 400 pharmacists had signed up to provide the extended care service in the county. Nick is not boastful but you can tell he is proud of the work Nottinghamshire LPC has done in recent years.

“I guess it’s tricky to claim credit for everything because stuff happens nationally of course with the direction of travel with advanced services but we’ve always been quite advanced in testing out new principles, new ways of working and new services,” he says.

“The common ailments service that’s being negotiated at the moment, some elements of the principle of that are based on the extended care service which is Midlands-wide which came from some of the work we did in Nottinghamshire, Derbyshire, going back eight years or so in very early CCG days. We did some work around UTIs and other stuff.

“A lot of the work LPCs do is based on trust and working corroboratively with our commission partners and that’s been built up over many years. We’ve seen people come and go and come back again.”

It feels like contractors all over the country have been told for longer than the memory can stretch that it’s not just what you know but who you know. Relationships count, especially if you want to benefit from local commissioning. Nick says he’s known Mindy Bassi for more than 15 years. If the name Mindy Bassi is unfamiliar to contractors in Nottinghamshire, it shouldn’t be. She’s the chief pharmacist of Nottingham and Nottinghamshire Integrated Care Board and, as Nick points out, has “been in senior NHS roles for quite a few years.” In other words, she knows some of the movers and shakers.

“That helps in terms of a working relationship,” he insists. “I worked with her before I was involved with the LPC. She’s well respected by pharmacists in the NHS. It's those relationships that build up over time that enable you to build trust and increase the ability to work together and work collaboratively.

There’s been a lot of tension

“By getting on with her and by building a relationship with her, we have a better working relationship with her team. We can work out how we can land various initiatives or mitigate stuff or put out fires.

“In the last few years, there’s been a lot of tension because everyone is under people-resource pressures and that becomes a flash point and people get more upset about things or sensitive about things, so quite a bit of work at the moment is around workforce and trying to diffuse tensions.”

We come to workforce a little later but for now, we settle on the broken price concession system, just one issue on a list that must feel endless for contractors who continue to dispense at a loss. In September last year, Community Pharmacy England said it was “escalating its concerns about the process for setting price concessions to senior government officials responsible for medicines supply” having warned the system was “not working in the current environment from a community pharmacy contractor perspective.”

Nick is asked if he feels that, almost a year on, CPE has escalated things sufficiently. “They are on some individual lines. It’s quite a tricky situation because as the name suggests, it’s a concession and it’s not embedded in regulation. It’s absolutely broken. It’s not working.

“My understanding is that ministers and CPE can’t come up with an agreeable alternative at the moment. Part of the problem, supply, is so complicated. We operate on a worldwide commodity market for medicine now. Ministers, the government and the Department of Health all want the better price and as far as they’re concerned, the model they’ve got with the global sum and the way pharmacies purchase, the retrospective margins survey works for them.

“It used to work for us but it doesn’t work for us at the moment because there’s so much cost pressure now and supply issue. It is hard. CPE have said in a number of meetings with contractors and LPCs ‘can anyone think of a better way of doing this?’ Everyone is scratching their heads a bit at the moment.”

One solution is for the DHSC to announce prices concessions earlier in the month but Nick is not convinced that will solve anything.

“The problem with that though is manufacturers and wholesalers will just bump the price up again because once it's gone on concession, they know they can then blame the system. And the chances are the Department of Health won’t review that one again.

“So as painful as it is, the price concession at the end of the month is more likely to reflect the true prices that contractors are paid, one that’s agreed at the beginning of the month because of the way the system goes.”

He suggests the concessions problem is complicated by other things such as manufacturer reimbursement schemes “at a national level as well as an ICB level” and branded generics. “All these things distort the overall picture,” Nick says. Then he considers whether a non-margin-based, fees-only contract would improve the situation before doubting if “we would get a consensus across community pharmacy contractors about that.”

“It would be an interesting question to ask and I know independents blame the multiples and the multiples blame independents. There’s a huge amount of blame going on,” he adds. If things weren’t complex enough, he suggests “Brexit and what’s going on across the pond and the rest of Europe doesn’t help.”

Then there’s the small matter of the MHRA taking “a licence off a company in India which has a catastrophic effect on worldwide supply” not to mention “countries that will pay more for their medicines because of the way their health system works.”

A couple of weeks before this interview, Community Pharmacy Nottinghamshire posted on LinkedIn that “the current situation with price concessions is causing grave cashflow deficits for many Nottinghamshire contractors, with the situation for many critical as they desperately try to keep their businesses afloat.”

Nick says he fears contractors in his locality will go bust. “I would say in my 30 years of being qualified, I’ve never known it to be as bad as it is now. This is the worst it’s ever been and it looks like it’s going to get worse before it gets better.” Some pharmacists, he says, “have had to put money in from their own pocket to keep their businesses going” and others are taking out “additional loans, dipping into their pensions, selling their car.”

And it doesn’t stop there. Nick says some contractors are reducing their opening hours and services. “There’s been a lot of hours in reductions, a lot have dropped a lot of days off. Some are being more considered in their deliveries. Rather than deliver to everyone, they’ll deliver to those who really need it. Some are not focusing so much on lower value services but the higher value ones.”

Concessions, of course, are not the reason why contractors are struggling but it’s undeniably exacerbating their problems. One pharmacist, Waqas Ahmad, suggested on Twitter that CPE should ask DHSC for evidence to justify how it reaches a price concession, perhaps through a freedom of information request.

“I think that’s a valid question,” Nick says. “CPE have tried to explain the process but I’m not sure it’s fully understood. I’d be surprised if CPE don’t know the process the Department of Health go through. Whether they’d release their data, I don’t know.”

He ponders the idea that the margins survey could be carried out more frequently. “Is that a way of doing it instead of looking at price concessions? But it’s open to too much manipulation. Why wouldn’t a manufacturer or wholesaler look to get the best price for what they’re selling? As far as they’re concerned, they could be selling widgets. They’ve got shareholders and investors to get a return for.”

Workforce issues more acute in some areas

Other considerations are no less important to under-the-cosh independents. Take workforce. Nick says everyone is struggling to find, not just pharmacists, but “pharmacy support staff and non-registered staff.” However, the problem, he suggests, is “more acute the further away you go from Nottingham city if you’re in Nottinghamshire.”

“I used to find in South Yorkshire, the further east you got, the more acute the problem,” he adds. “You can’t fill posts for counter staff. It’s hard work working in a pharmacy, whatever level you’re working at. It’s an employees’ market, therefore the non-qualified staff, non-professional staff, are looking at other employers and going to work in other industries because it’s really hard work.”

National Pharmacy Association chair Nick Kaye recently said the locums he employs to work in his pharmacy in Cornwall have put their rates up. He called for locum costs to be included in contract negotiations. Nick Hunter agrees.

“Yeah, I think they should. They are a fundamental part of the way a pharmacy operates. All costs should be considered. Rent, rates, like power, everything has gone up over the last year, two years, five, 10 years.”

And, shock, horror, he’s not sure hub and spoke “is an efficiency that will save money” even though he accepts it creates capacity. “If hub and spoke was financially more efficient, then the multiples would be doing it on a much larger scale than they currently do.”

Another bone of contention is whether general practice pharmacy, through the additional roles reimbursement scheme, is worsening workforce problems in community. Talk to a GP pharmacist and they’ll likely tell you you’re talking rubbish. But speak to a community pharmacist and you’ll probably get a different response. Nick is unequivocal.

“The ARRS must be a massive factor in the workforce issues we’ve got in community pharmacy. It’s not just community pharmacy, it’s even effected pre-ICBs, the CCGs. I know that CCGs couldn’t fill pharmacist and pharmacy technician vacancies in their teams as well because of the suck into the PCN roles.”

And yet he has detected “some drift back with some pharmacists” into community. “I think what a lot of pharmacists would like to do is a bit more portfolio working and use some of their skills they currently use, or feel they can only use in PCN land, better in community pharmacy.

“Some of that high-level clinical knowledge such as structured medication reviews as independent prescribers, I think a lot of them would like to do that in a community setting. There’s no good reason why they couldn’t if the commissioning structure was in place.”

Pharmacists should be free to choose to work in community pharmacy or in general practice but that hasn’t stopped people speculating over whether pharmacists in practices have good job satisfaction or provide the NHS with value for money. It’s what prompted Rowlands Pharmacy superintendent pharmacist Stephen Thomas to call on NHS England to research the matter and publish its findings.

It’s lonely being a practice pharmacist

Nick says some have come back to community because they have felt “very isolated” in a practice, particularly pharmacists who thrive on seeing patients in the flesh.

“You don’t see so many patients and a proportion of your work is done on a computer rather than necessarily seeing a real person. Some of that will be remote conversations, telephone conversations but some of that will be reviewing a patient’s notes.

“Those who really like that patient interaction and that team-working that you get in a community pharmacy, they’ve struggled with that and they come back.” He says some pharmacists work part-time in community, part-time in general practice. He agrees, by the way, with Thomas’s suggestion of that NHSE research. “A cynic might say they haven’t published that because actually, they know they’re not actually doing what the intention was for that ARRS-funded role,” Nick says, with no hint of mischief.

Not that he’s giving community pharmacy a complete pass. He says the sector is “really poor at developing its workforce” but that’s because “the commissioner doesn’t commission in a way that encourages workforce development.”

“If commissioners commissioned in a way that said ‘this service is going to be delivered by pharmacy technicians and the return opportunity for that is favourable,’ community pharmacy would invest training pharmacy technicians by the shed-load.

“At the moment, Health Education England are saying ‘why aren’t you training technicians?’ Well, there’s no purpose for that, we have no need for technicians. They’re nice to have but actually, the current model of work means we can do that with pharmacy assistants.”

He challenges commissioners at the DHSC and NHSE to “get a lot smarter” by joining up “some of their commissioning and stop commissioning in isolation and making it worthwhile by funding core better.”

The present is gruelling but optimists would point to an exciting future. Independent prescribing will open new doors but the cynical hack in me can’t resist asking him if it might open a can of worms. Once all pharmacists become prescribers upon qualifying, could some manufacturers try to influence them to prescribe certain medicines?

“I think it is a risk,” Nick says. “We need to think how we mitigate that, how we make the best use of IT to support that. It’s a risk with dispensing doctors forever and a day. It’s not a new risk but the scale potentially can make it a more significant risk.

“Also, there are independent prescribers in community pharmacy and some of them are doing work for the NHS. You’ve got some working in general practice as prescribers as well. What’s the difference between the financially perverse incentives for any contractor who’s also an independent prescriber and working in a GP practice next door to their pharmacy?

“But it shouldn’t stop us doing stuff. Independent prescribing absolutely has to be the way forward for community pharmacy.”