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Dark clouds are gathering


Dark clouds are gathering

The root cause of most challenges to NHS productivity is chronic underfunding coupled with incoherent piecemeal strategies. This will not change under integrated care systems, says Mohammed Hussain


The former MP and Secretary of State for Health in 2005, Patricia Hewitt, published a review into the oversight, governance and accountability of integrated care systems (ICSs). This has become known as the Hewitt Review.

As is always the case with such reviews, it sets out that there is a once-in-a-generational opportunity to improve the NHS through greater integration with social care and local authorities through greater autonomy and accountability, and by focusing on the four key statutory priorities of ICSs. These are:

  • Improving health outcomes and services
  • Reducing health inequalities
  • Financial stability, and
  • Supporting communities’ social and economic development

There is nothing fundamentally ground-breaking in this review, but it does continue to build on the themes we have heard in recent years. Everyone agrees we need greater integration with social care, make better use of data, and to address the productivity challenges in the NHS.

Although only mentioned four times in the 89-page review, it was refreshing to see pharmacy issues highlighted in such a high-level NHS review. Hewitt raises concerns about the impact of pharmacy closures on patient care and identifies the workforce challenges caused by increasing numbers of pharmacists moving to GP pharmacist roles.

She highlights the opportunity for ICSs to make better use of the available staffing resource across the Place or system to provide a more integrated whole primary care offer for communities. Pharmacy is also mentioned in regards to helping address digital inclusion by assisting patients to navigate their digital care needs.

This is certainly an area where pharmacy has been offering informal support, so it is welcome to see it acknowledged and I hope that this becomes a new enhanced service akin to citizens’ advice, helping patient navigate their care with digital tools.

I also welcome the proposal for a national user group to inform and guide the future development of the NHS app. The use of the NHS app as a platform for managing care is a success and to build upon this a greater patient voice is very welcome.

ICBs have now assumed responsibility for the commissioning of pharmacy, optometry and dental services in their areas. This is cited as another opportunity to improve integration and care delivery, but this is an area I have genuine concerns. The principle is sound, but the challenge is that the ICBs are being handed an impossible task.

Centrally dictated efficiency savings and yet another NHS reorganisation is leading to a loss of experienced managers, together with reduced funding. ICBs cannot possibly fulfil their ambitions with fewer people and less funding. This will be another failure of effective commissioning due to the strategic failure to sufficiently invest in primary care.

ICSs and ICBs herald yet another endless cycle of premature organisational restructures in the NHS, just as the dust settles from the previous changes. A cynic might argue that this is an easy way to demonstrate that action is being taken, that the government has a grip, but in reality, this only gives the impression of improvement whilst distracting the NHS and the workforce away from their health delivery focus. There is only so much bandwidth in any organisation.

Any of the NHS organisational structures in the last 20 years could have delivered the desired improvements in service if simply left to mature. There is no optimum NHS structure. This is the lesson that needs to be learnt, but for reasons of political tinkering, I doubt this will ever be the case.

The root cause for most of the challenges in NHS productivity and workforce is chronic underfunding coupled with incoherent piecemeal strategies. This will not change under the ICSs or any other three-letter acronym for a new organisational unit that arises in the future – remember primary care trusts and clinical commissioning groups?

In pharmacy, we saw last month the imposition of additional funding cuts on generics reimbursement, with the clawback discount going from 17.5% to 20%. This is no way to invest in the future of the primary care network.

Pharmacy closures will continue just as the NHS needs the pharmacy network more than ever.


Mohammed Hussain is an independent contractor and non-executive director of Bradford Teaching Hospitals Foundation Trust.




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