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Lots of detail still to come on five-year pharmacy deal

What do you make of the five-year CPCF deal? Our correspondent’s first impressions are that it is like a curate’s egg … and there is an awful lot of the detail still to come…

 

 

“The period of 20 years from the last time the pharmacy contract framework got an overhaul, to the middle of the 2020s, will embrace a period of change, particularly in pharmacy practice, greater than the whole of everything since the founding of the NHS.

“In all our plans for the future, we are re-defining and we are re-stating what community pharmacy can provide in terms of this revolution. But that revolution cannot become a reality unless we are prepared to make far-reaching changes in the economic and professional attitudes which permeate our whole system of practice.

“The new face of community pharmacy that is going to be forged in the white heat of this revolution will be no place for restrictive practices or for outdated methods.”

So said PSNC chief executive Simon Dukes last month when the details of the 2019-24 contract settlement were revealed ….

Well, he didn’t say anything of the sort actually but, like Harold Wilson back in 1963 when he opened a debate at the Labour Party conference (and whose words I have cannabalised), he knows that this deal is going to take some selling, and like the proverbial five year tractor plan, it is going to take some delivering.

So I am writing this column just days after the news of the new five year CPCF deal was released, and I can’t say I have properly got my head round it yet. These are very much my initial impressions, gained after wading through the slew of documents that accompanied the announcement. The devil is often in the detail of these things, and while there is plenty of vision there isn’t much detail … yet.

It could have been worse. I think we have to take PSNC at its word when it says the government was planning to cut funding further in 2019/20, so let’s take the fact that funding has stayed the same as in 2018/19 as a plus. But a big minus is that it stays the same as last year and will stay the same for the next five years.

Five years! In business terms this is a lifetime. Even If inflation stays steady at around 2 per cent it means another five years of diminishing returns. I accept the settlement offers some stability (Cat M permitting), but I’ll be interested to see how my bank reacts to the news. I doubt it will improve my credit rating!

Margin remains untouched. The dispensing fee is fixed. There are the usual bland assurances about smoothing cash flow, making margin distribution fairer and reducing the burden of bureaucracy. Hub and spoke is back on the table, albeit with PSNC claiming it will only agree to models that will treat the whole sector fairly.

In my book that means hub and spoke remains a threat, since unless the NPA (unlikely) or my wholesaler (more likely) is able to offer me a hub facility I can tie into, I will be hard pushed to reap any of the anticipated benefits. Any efficiency savings in dispensing will need to be pursued though, because I can’t see much else that is going to offset the ongoing erosion of real income.

It seems pretty clear that there are people in DHSC and the Treasury that are still not convinced that community pharmacies provides value for money and we, as a sector, have yet to persuade them otherwise. Although it wasn’t explicitly stated in the settlement, it is clear the government still wants to cut pharmacy numbers in England.

“Funding is still supporting more pharmacies in some places than may be necessary,” the agreement says. Financial attrition has produced reasonable results so far, and with five years of fixed funding the mandarins in Whitehall have every reason to think it will continue to do so.

I think they are probably right. I’m not sure what the actual figures on closures are since December 2016, although I seem to recall a figure of around 230 being bandied about last month. There will be more, and the risk is that the trickle will become a flood. Of course, if your pharmacy survives you could earn a larger slice of the remaining cake….

So what about the rest of the package? I can’t say I am weeping too many tears over the demise of MURs. I enjoy talking to patients about their medication, and probably spent more time doing so than I should, but the fees aren’t great.

The target driven approach adopted by some multiples has undermined their value and, from a professional perspective, I get fed up with most of the recommendations I make being ignored by our local doctors (who probably never have time to consider them properly). GP pharmacists have to do something to justify their existence and structured medication reviews fit better with them.

Anyway, with funding capped, something had to go to give us any chance of delivering the new Community Pharmacy Consultation Service. This is part of the deal that gives me some hope. The vision and the development timetable for new elements of the service are there. It fits in with the often stated wish to shift the focus of what we do from dispensing to services.

Most importantly it is a national service. The pharmacy contract framework put together in 2005 aimed to enable local commissioning of services. That hasn’t happened to any meaningful extent, and even if pharmacies successfully integrate with PCNs, local services will still be hit and miss.

Nationally delivered services are the way to go, and the CPCS has to be recognised as a serious attempt to move community pharmacy in this direction. It’s going to be hard work though, and PSNC and LPCs have got their work cut out managing the timetable and the pilots.

As a sideways thought, it looks as though a seismic shift in our IT capability is going to be required to deliver some of the aspirations in the CPCS. The transitional payments we are promised might cover this (unlikely) but more of a concern is that the applications we really need are simply not there. PMR systems are stuck in ‘supply’ mode and offer little of the CRM approach the new services will need. Can PharmOutcomes ride to the rescue?

The continuation of the QPS, rebranded as the Pharmacy Quality Scheme, is no bad thing. It’s like one of those cough mixtures that pharmacies used to concoct, and which your mother used to force down your throat with the advice that it might taste horrible but it would do you good (did anyone ever like mist ammon et ipecac?).

I’m prepared to live with a national quality scheme provided the criteria are sensible and can be achieved by the majority with reasonable effort. But the PQS must not become a means of stuffing ever more requirements into the Terms of Service at no cost.

I could go on... At least we got a deal, albeit a day before Boris was bounced into No 10 (elected by fewer than 100,000 unrepresentative Conservative party members) and the Cabinet and politics generally went into meltdown (again). I don’t think it is unrealistic to say that no agreement in July could have meant no agreement for at least six more months.

But the fact is that the precarious financial position that many pharmacies are in does not provide a solid base from which we can step up to deliver on the transformational elements in the five year deal. In summary the deal offers good vision, poor incentives and high risk.

I agree with NPA chief exec Mark Lyonette when he says: “The government must be prepared to direct more money into community pharmacy, if it becomes clear that funding is insufficient to maintain current core services and invest in positive new developments like the CPCS.”

Then again, pigs might fly!

 

 

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