Advocate of the Year Dilip Joshi hits problems with local authorities over contracts for services, but enjoys a regular event with King’s College pharmacy students

Tuesday, March 4

There have been more Call to Action (CTA) meetings locally (and I suspect nationally) in recent weeks than on any other topic and, this evening, I go to a local practice forum (LPF) event and see many of the same faces I saw at other CTA meetings. We are told that the Primary Care Strategic Framework, to be launched in October this year, will be based on CTA responses and we have a unique opportunity to make the voices of our profession heard.

In a presentation, Dr David Geddes, head of primary care commissioning, cites NHS England’s ambitions for primary care to be proactive, coordinated, holistic, person-centred, fast, responsive, health-promoting and consistently high-quality. In a healthy mix of optimism and cynicism, I reflect on these adjectives and wonder if this wish list is new or ground-breaking in any way. The challenge has always been to have the right framework and resource allocation to enable what are, after all, aspirations as non-controversial as motherhood and apple pie.

As a practical example of an enabler, better alignment of rewarding work in GP and pharmacy contracts would encourage cooperation rather than competition, reduce duplication and have a much better chance of meeting Dr Geddes’s espoused goals. Optimism just wins and I leave the Call to Action meeting hopeful that, this time, outcomes from the consultation will result in action.

Tuesday, March 11

On duty at the pharmacy today, I conduct an MUR for a patient who reports taking her medicines when she remembers – this is usually on the right day but times could vary. I reflect that frequency and timing of taking medicines has a big impact on outcomes. I suggest strategies such as association with other daily activities to help her remember; and I report to the GP that the patient might benefit from reviewing her dosage regimen. At medicines management meetings, I have seen recommendations being made for cheaper formulations based simply on cost. Some of these need to be taken more frequently than once or twice daily. With medicines optimisation in mind and studies showing more than a third of medicines not being taken as intended, policy-makers, prescribers and pharmacists need to be aware that a blanket policy that does not consider the individual needs of patients is entirely inappropriate and ends up being more costly in the long run.

Thursday, March 13

I attend the Ask Your Pharmacy Team (AYPT) event at King’s College School of Pharmacy for the third consecutive year and am amazed by the enthusiasm, motivation and drive shown by final year students in carrying out their research into public awareness of pharmacy services. Senior members of staff, including the head of school, Professor Peter Highlands, the Department of Health’s Gul Root, the NPA’s chief executive Mike Holden, and the Lambeth clinical lead, Ash Soni, attend as in previous years, together with members of the pharmacy press and patient group representatives.

I am in the chair and motivational words are spoken by invited guests before the main event in which the lead student (Vanshri Shah) presents the research findings. Year-on-year, awareness of pharmacy services has increased, as has the willingness to access new services – flu vaccinations, for example. Unsurprisingly, the use of the internet, especially amongst younger people, has also increased and people are generally better informed when visiting pharmacies to ask for advice, although there is the worry about reliability of online information, its accurate interpretation and anecdotal advice being posted by the unqualified.

_{Left to right: Jayesh Patel, Vanshri Shah, and yours truly at the King’s College event}

Following formal presentations, there is an opportunity to speak to students and understand their concerns and aspirations. Again, I am impressed with how they want to improve the health of their patients and see their role as key contributors in the health service. Many, however, are concerned about employment prospects and feel the increase in numbers of students qualifying means there is greater competition for places. This workforce issue will need to be addressed if our profession is not to become devalued over time.

Monday, March 17

I am at the Lambeth Borough Prescribing Committee today and, recalling my earlier experience with an MUR, take the opportunity to suggest decisions be based on optimisation rather than on cost alone – there is a tendency to speak about optimisation then make decisions heavily influenced by cost savings.

Healthcare professionals continue to work in silos, with prescribers prescribing and dispensers dispensing; MURs are a valuable mechanism that provide ‘sense-check’ and feedback, but patients need to be better supported in taking their medicines. I recall an incident at a care home where two tablets of similar appearance were interchanged for someone in their 80s: a sleeping tablet being given in the morning and a diuretic at night. Imagine the effect of that on the quality of life of the person concerned!

Tuesday, March 25

Today, an insurance issue emerges in negotiating transition of public health enhanced services (PHESs) to local authorities. Local authorities have standard contracts that have evolved to penalise errant contractors – in particular, we are told, construction companies that have left work unfinished meaning the council had to find alternative contractors to finish it. These contracts were of high value and with large companies.

We argue that such standard contracts are not fit-for-purpose for small PHES contracts and a requirement that providers must cover the cost of a local authority obtaining a replacement provider in case of non-performance is unrealistic. It emerges, through NPAI advice, that non-performance of contractual obligations is not insurable under a normal policy and requires the purchase of a costly performance bond. Most insurance companies (including NPAI) are not licensed to provide this type of insurance and, in any event, would not want to see it against their balance sheets.

After much discussion, we manage to remove the clause in Southwark and limit it to 20 per cent of the annual contract value in Lambeth – the latter due to Lambeth’s legal team insisting on some form of token assurance. The LPC team reflects that this will be an issue for all LPCs and notifies NPAI and other pharmacy bodies. Principally, local authorities do not understand commissioning local healthcare and have, fortunately, retained ex-PCT expertise during the transition phase in our area.