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Suggested Learning

Reaching for the unachievable

The solution is to add core services to the national contract

Independent proprietor Sid Dajani analyses the current state of the NHS and considers the way forward

Let’s say you were responsible for running pharmacy UK and developing the vision. Just pretend. Imagine you are in your mahogany-lined office on the 35th floor and you hear a timid knock on the door.

Enter the chief executive officer. Slightly stooped, he produces a spotless, freshly ironed handkerchief and nervously polishes his gold, round-framed spectacles. He slides a spreadsheet across your desk, clears his throat and murmurs: “These are the pharmacy numbers for the last quarter.”

He takes a step back and waits for your reaction as you read the headlines. You discover that none of the advanced services have hit their targets and 80 per cent of enhanced services are running at a loss for various reasons.

There are several things you could do. You could pull out the top right-hand drawer, take out the pearl-handled Smith & Wesson .38 and shoot him. Shooting the messenger is a gratifying, autocratic, time-honoured way of dealing with bad news.

Other options

Or you could dismiss the CEO, stroll over to the other side of your office, open the cocktail cabinet and pour a glass of Macallan M from its Constantine decanter and roll the buttery creamy gold around your tongue, closing your eyes as you take in the brown sugar, marzipan, butter icing and sultana undertones. Relish the rich dried orange peel, fragrant sandalwood, riverbank earth, damson jam and tingly spice flavours; feel it slide effortlessly down your throat. Then shoot yourself.


Other options are to call a meeting of the pharmacy organisations and beat them up, plead with the Department of Health and the Treasury for more time and money, embark on a programme of dispensing fee cuts and clawbacks, prevent commissioning of pharmacy services and escape with your shirt. Or, you could hire someone to do a root-cause analysis and see what needs to be done.


As I write, the NHS is going into meltdown. Junior doctors are planning to strike, we need 20,000 more GPs costing hundreds of millions in training and wages, capacity at A&E has meant emergency patients are in corridors, we have an ageing population with ever increasing age-related morbidity, Social Services are stretched beyond the physics of elasticity, NHS staff are frazzled. and everyday we read the NHS is creaking like a pantomime dame's corset.


Judging by my patients’ experiences of the NHS, what we have now is a tangled, fragmented, unmanageable mess because good, qualified, well-intended, energised people are working in a sclerotic, underfunded, impossible environment they know they can’t make effective. All this despite a backroom reorganisation that’s frankly wasted £3 billion, fragmented the NHS and made integration harder to achieve.

Shifting the focus

No wonder the government wants to focus on foreign shores in an attempt to forget its own headache back home. Hopefully its foreign policy will fare better – not that it’s a got a great track record there either. It’s bombed public health funding that would help reduce NHS treatments, magnificently shot down the merits of a national common ailments service that would get people treated quicker and keep them out of A&E and GP surgeries, refused to accept that commissioning is about as scarce as Lord Lucan, and failed to target those CCG GPs who've been marinating in self-interest for too long, thus leaving our skills redundant.

General Custer was undone by too many Indians. General practice has too many patients. It's a fulcrum point, a lever for change, a tow-rope to pull primary care out of a hole and give it a kick-start. Putting pharmacists in GP surgeries is not the answer to this problem – the problem is that the NHS commissioning system overwhelmingly shuts community pharmacy out. The solution is to add core services to the national contract – that would deliver the pace and scale the NHS needs, but will only happen if NHS England makes it happen.

If Secretary of State Jeremy Hunt wanted to, he could make it happen. But Jeremy Hunt is ignorant of pharmacy. All he can see are doctors and nurses. Every now and then he utters a few platitudes about pharmacy, but in truth it’s just meaningless political rhetoric.


Where they have involved us, we’ve delivered. Sure, flu jabs may be down despite our participation, but how much worse would the figures have been without every bit of pharmacy heaving, sweating and straining to pull services through despite our sudden inclusion?

More collaboration please

I'd also argue for some kind of joint incentive with other primary care contracts. There is a real issue with GP collaboration in that no one is clear what we are supposed to be collaborating on. We need the new contract to reflect where that shared need is. Currently, MURs are a nuisance to GPs because they don’t fit into their contract or the quality and outcomes framework (QOF).


There is no incentive or need for GPs to contact pharmacists about anything. Some have very good working relationships with us, but in other cases there is no relationship at all. If the contract required the professions to make use of each other, it would lead to greater mutual understanding.


Aligning our enhanced tier of contracts can only be a good thing, despite the fears of Sue Sharpe and others who have much to protect, just like GP commissioners. I’m sure there'll be implications, reverberations, repercussions and exacerbations – you need time to shift and weigh the evidence, review, research and consult, but if done right it could be a phenomenal success.


The NHS is working really hard, and there’s plenty of sweat and effort from its individual parts, but it's not working in the sense of a Swiss watch. We need more funding for community pharmacy and even for second pharmacists because we can’t continue to have an NHS that is built on the unmanageable, run by the unbelieving, and reaching for the unachievable.




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