Healthcare is not a business

Healthcare is not a business!

Today I was reading a report talking about healthcare as an ‘industry’, a business. This language is unhelpful, but does demonstrate how wrong we have got things. A business works to satisfy customer needs profitably. It is built on three line accounts – revenue, expenditure and profit. We would drive up demand to build revenue, control expenditure to increase profit. We might diversify and introduce new services to ensure that we can continually grow the range of customers, the services/products that we offer to continue to build revenue. When times get tough we review expenditure and look to new ways of growing revenue to ensure a constant or growing profit.

The NHS and Social Care is different. There is no profit and we just have to match revenue – whatever the government gives us – to expenditure. It is stupid to drive demand when revenue does not match it. We end up with overworked and demoralised staff, a restriction to new technologies and growing risk because we can’t guarantee quality. For the Department of Health to talk about 500,000 more A&E attendances and millions more GP appointments in extended hours is just a measure of failure and an extra 2.1% in staff as a measure of success is frankly ridiculous.

Demand will be the death of the NHS and we need to do more. So let’s start an open discussion.

Managing demand.

While demand increases we need to look at less expensive ways of delivering care. We all know that A&E is more expensive than OOH, which in more expensive than General Practice, which is more expensive than Community Pharmacy. Urgent and emergency care collaborative should include all providers of first care and the investment and effort should be in the least expensive provider. This should purvey thinking and investment strategies. Initiatives such as ‘PharmacyFirst’ should be supported. I note that the Secretary of State feels that NHS England has made good progress in supporting community pharmacy reform – but I would generally disagree. It is about time HEE was supported in offering training opportunities to community pharmacists outside of commissioned services. You are simply wrong to expect them to take up the slack without supporting their development. The core contract cuts may have encouraged community pharmacy to adopt a new business model (now they are real businesses), but the reduction in commissioned services is not helping. Perhaps 10% of NHS111 referrals to General Practice could have gone to community pharmacy. 1.2million GP appointments could be saved this winter through the Strep A sore throat test and treat service and simply creating a direction of travel might save more appointments.

When you see stresses in the system you need to work out how to relieve them, get other services involved, find other ways rather than simply funding more of the same.

This is where ‘business’ is important. Community Pharmacy is a business – if you cut its revenue then expect a reduction in services to compensate. It is just not the way to do it.

Reducing demand

We really have to start considering ways of creating health as a mechanism to reduce demand. This is not about engaging lower cost healthcare providers, but not having to engage a provider at all. It is about creating the situation where people can be in Control of their health, Connect with others and have Confidence. I am seriously worried about the paternalism in the NHS that always wants to define what is right for me. The way that we run the NHS simply traps people in the system and we need to set them free to create their own health, take control and make their own informed decisions. The Government should support situations which increase our ability to be in control. I am sure that people know the better decisions and would take them if it was easier to achieve.

One day the NHS will support the view that it is my health and my condition; give me access to the monitoring and testing without visiting my GP. GPs are not responsible for my condition – I am – and I should be able to ask GPs to advise me on the best ways for me to control my condition.

Health creation is the only way forward to reduce demand. Now we have thousands of healthy living pharmacies – how can we develop them to adopt health creating practice and be in a better position to help communities create health?

So in conclusion – healthcare is not a business, but community pharmacy is – just think about it.

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The new pharmacy

It is a funny time.

All I hear are discussions about the term ‘clinical’, about supervision, about the law suites and about shortages of medicines. A Pharmacy isn’t a Pharmacy without a pharmacist and you can’t separate supply from clinical services. There seems to be a mist falling demonstrating the whole professions wish to move backwards into the good old times and reluctance to move forwards. The eloquent ask for one voice – but saying what, on behalf of whom, delivering which future? It might be time for a different voice talking about a different future.

I have heard chatter in the backroom about a new breed of pharmacy. The one without a dispensing contract with the NHS. It is not unheard of – the dentists did it – but despite the chatter and the goading – I have not seen a Pharmacy do it.

Now this is the real question. Could a pharmacy survive without an NHS contract? What would it do?

The first thing to suggest is that it won’t need its dispensing technician and ACT, but it will need a pharmacist and a team on the counter and the appropriate support staff. The overheads would still be £100 an hour, so it would need to put at least £300 into the till every hour to make a profit. Surely this is break –even, but you can probably can expect 30% margin on products, but higher on services.

So there you go – start thinking – here is your challenge for today.

  • Multi-professional location – I would rent out one of my consultation suites. Perhaps a podiatrist or a physio – something that will bring me an income and footfall of the type of customers that I am looking for.
  • Products – I need to sell £100 an hour – so I need to stock a different range, something that is specific to me, something that people might travel for.
  • Services – I need to sell £200 an hour. I can include public health services such as stop smoking and weight management, but I need to expand these.
  • Marketing – the customers that I need are not in the Pharmacy. I have to go out and find them, create awareness and draw them in.

When you start thinking about it, it might work. It might have to when the dispensing contract needs to be subsidised by other income and prescription numbers fall.

There is a question to Dr Ridge here. Could a Pharmacy operate under an NHS contract and not dispense NHS prescriptions? Could it opt out or have a restricted and specified element? Would it be able to deliver MURs and NMS services in association with a local GP practice and contract locally for Immunisation, minor ailment, domiciliary MURs and other public health services?

Will some Pharmacies become ‘health and wellbeing hubs’ and will we see new non-dispensing pharmacies opening?

 

Community Pharmacy – fighting against the tide

I see many community pharmacists and pharmacy owners as the new King Canute of today. They valiantly try to hold back the tides of change. It must be clear to everyone that remote dispensing and supply will be the norm once the multiples and Amazon get into the game. Every week I am contacted by either P2U or Lloyds asking me to have my medicines delivered. I hold out and support a Day Lewis branch – yes I thought highly of Kirit, but the truth is that I would be inconvenienced if it closed.

I still hear people say that supply and clinical services must remain linked and those that talk about the value of face to face services and I remind people that appliance contractors have been supplying Appliance Use Reviews as part of their contract for quite a while. Just look at the way public health services are going – all on the internet and self-help, because they can’t afford to run premises. The current MUR needs a ‘major tweak’, and it is going to get it.

Walking through into the 2010’s you must realise that you need a new set of relationships. You must realise that NHS England has stimulated all pharmacies to work to healthy living pharmacy status. They have put the framework in place, but they don’t have the money and neither do public health in the Local Authorities.

If you follow ‘Jerry Maguire’ (not the excellent Mike Maguire from up north) then shout – ‘show me the money’. It doesn’t sit in NHS England and it doesn’t sit in the Local Authority – it is in people’s purses and pockets. Stop looking up to the heavens and start looking down at people – and not just the ones that are in your pharmacy – you know the ones that won’t pay – but the ones in your street, in your community that will pay. I often remind Pharmacists in places like Tower Hamlets that 10% of the working population earn over £100,000 a year.

Community Pharmacy needs to develop different relationships with more people. We have to become the first stop for healthcare and provide a linked range of service and product offerings that people want. As more people are interested in their own health and wellbeing – community pharmacy has to be the answer.

Community Pharmacy also needs to develop new relationships with other providers. If General Practice has too many patients and community pharmacy needs greater footfall…… think about it.

The longer we think we can hold back the tide – the less we are prepared for the future.

Is the NHS chasing pavements?

The NHS seems to be always chasing pavements rather than getting to the point and sorting things out. It has never been about structure and competition – it has always been about relationships and working together. It cannot be all about illness, but must focus on wellness and health creation. It is not about access it is about demand.

Demand has two elements:

Can we share demand – bringing other players in to share the load?

Can we reduce demand – adopting health creating practice and giving people control, connection and confidence?

GPs will tell you that there is too much bureaucracy, the payment systems are fractured and there are too many boxes to tick and too many meaningless pathways. But they will truthfully say that demand is the killer. More patients, with more expectation, more complex conditions and getting older; delivering care to the quality that they desire and making a decent return on a lifelong investment in their practice is becoming impossible.

Many practices have reorganised, included more nurses and practice pharmacists in the attempt of becoming more efficient and absorbing/distributing the workload. It is working, but nurses are difficult to find and the pharmacist programs needs to be accelerated. I hear that my local CCG wanted 26 and got none from the last round. Too little or too slow or both.

But there is a glimmer of hope. The GP federation is sitting down with the Local Pharmaceutical Committee and laying some cards on the table:

GP – we have too many people entering our service. Many have minor or self-limiting conditions; need some monitoring or a follow up test. The sheer volume and growth occupies increasing amounts of our time. It is great to talk to our practice population, but we need a form of out-of-practice triage.

Pharmacist – we have too few people entering our service. Over the years we have focussed on the dispensing element and then adding value to the safe and effective use of medicines. 90% of our income might be focussed on this element and the NHS has now cut this significantly and told us that we have to change. We need more people that have minor or self-limiting conditions; we can do some monitoring and provide other services. We want to look after more people and service their health needs and help them to create health.

Did the penny drop – the lightbulb come on – eureka – an epiphany?  Actually there was a little ‘chin-scratching’, followed by a GP pulling up a note about the Strep A sore throat test and treat service via the innovation network; did you see the research in Eccles on minor ailment services; did you know we could do this test, make that diagnosis, offer these medicines.

Of course the CCG came up in the conversation –“ they want us to stop prescribing these medicines – its difficult – could you help?”.

So the game has started, the relationships are forming, ‘one primary care’ is becoming a reality. I really hope that the Pharmacists are invited to join the federation. I also hope that the CCG will get behind it and NHS England will show some interest – it will be unforgivable if they don’t.

Stage one started – the community pharmacists are going to share the demand and reduce the pressures in General Practice. Stage two – we need community pharmacy to move from healthy living pharmacies to health creating pharmacies. That will come next.

I have no idea where this will go. I do know that the NHS desperately needs community pharmacy to take a bigger role. And my fingers are crossed that people will be interested, very excited and very committed to delivering an answer rather than chasing pavements.

Mums the word

Childbirth is tricky. Mums may have been doing it for ages and many people call it natural, but the truth is that it opens up the mum and the baby to some risks. In many ways Mums need to be prepared and there are many groups out there that are set up to help. We also keep talking about choice and Mums have to listen very carefully to the advice that they are given and then try to make the best choice for themselves

Some community pharmacies are setting themselves up to help and provide advice and a range of services that would help a mum to be ready for the birth and when looking after their precious baby.

Why community pharmacy? Well that is simple – they are the most accessible source of healthcare advice and represent choice and convenience.

The pharmacy often starts the process by offering for sale the pregnancy test, but there are a number of other things that they can offer during the pregnancy and after delivery.

  • Influenza vaccination. Obviously the NHS would want 75% of pregnant women to receive immunisation, but we are a long way of that. So the Pharmacy team may have an important role to try to increase the immunisation in this particular group. There are other important immunisations mentioned here https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/510981/9738_PHE_Pregnancy_DL_16pp_leaflet_13_web.pdf
  • Assessment and treatment of anaemia. Anaemia is relatively common during pregnancy. A simple and inexpensive test will provide a Haemoglobin level and haematocrit within a minute. Women with low haemoglobin measurements may be offered a suitable over the counter products and retested at a later date. You may wish to consider point of care tests for HIV and Hepatitis B.
  • Group B Strep Awareness and test. Group B Strep is carried by 1 quarter of all women through their pregnancy. The bacteria can be transferred at birth to the baby. A few babies will develop a Group Strep B infection that might include a chest infection right through to meningitis and sepsis. It is the most common cause of sepsis in the newborn. Despite a number of petitions the UK does not recommend universal screening, but both NICE and the RCOG recommend routine intravenous antibiotic prophylaxis to carriers. Community pharmacy in association with the Group B Strep Support charity are well placed to both raise awareness and offer for sale a test recommended by Public Health England and not routinely available in the NHS.
  • Supportive care on minor conditions. Things like reflux, back pain and stretchmarks may not be minor conditions, but a community pharmacist would be well placed to offer advice on suitable remedies, taking into account salt content and general applicability.
  • Support post-delivery. Mum and baby can have a wide range of common complaints from sore nipples and tiredness to nappy rash, childhood dermatitis and wind. The pharmacy team will be able to offer advice and a range of helpful solutions to most common problems. Some pharmacies offer advanced feeding advice for those mums which struggle to breast feed or use standard formulas.

It is very important that Mums always get good advice and support and the community pharmacy may be just the right place

Community Pharmacy in Crisis

Several years ago (2013) I wrote a blog called ‘dispensing on the Titanic’. I have to admit that I never expected community pharmacy to be so resistant to change and that the government left it so long to act. But it is here and now and the impact is larger than we might have expected.

Community pharmacy is in crisis – there is no two ways about it. The drop in income is significant. The change to a more clinically focussed, professional retail healthcare service has not happened.  The NHS commissioning has slowed or gone into reverse. Local co-operation is struggling. And what’s more we are still not prepared for change.

All in all it is a disaster. But it doesn’t have to be. At last every community pharmacy has got the message – change or go out of business – there is little doubt about this now. There is no saviour waiting in the wings and vote grabbing promises mean very little in a country that just doesn’t have the money to fund everything.

It is down to us – that is the only thing for certain. It has to start now – we need to invest before things get impossible to change. And we have to be fast – driving new income streams is the most important thing.

  • Premises – we do have to consider the look and feel of our premises – it is not about nice shelves, but do we look and feel like a professional clinical retail healthcare environment.
  • Staff – are we dressed properly, engaging and informative? Are we moving from being reactive to proactive?
  • Products – are we looking at products that differentiate us?
  • Services – are we delivering services that people want and need?
  • Marketing – are we reaching out to the right customers who want our services and products?
  • Training – are we able to access the right training and experience to deliver different services
  • Co-operation – are we able to build together, sharing some experiences and expertise and the will to be a commissionable force within primary care?

Every month we bleed a little more. In 2013 we said it was ‘Now or Never’ now it really is.

Community pharmacy on the launchpad

So the first round of quality payments has been submitted and I understand that community pharmacy compliance will be outstanding. I am genuinely happy, both for the community pharmacies and for the Chief Pharmacist and his team who may have dragged community pharmacy into the 21st century.

What was that? What did I say? Did you hear me right? Yep – community pharmacy are on the Launchpad to greater things thanks to that little masterstoke introduced at the last contract imposition. A little unfortunate that it was hidden in the cut to core service payments and the pharmacy integration fund. And I hope that you don’t think of it as a box ticking exercise.

If you wake up tomorrow and find out that the NPA or PSNC has won their case, let’s not forget that an important job will have been done.

So every pharmacy will be delivering at least one advanced service. They have all updated their NHS Choices entry – although I never understood why they wouldn’t want to tell everyone about the services that they provide. They all have a secure NHS email address – so they can transfer information to and from their main paymaster securely and perhaps they will be more responsive to requests etc. And they are all using EPS.

Brilliant

Every pharmacy will now record and act on patient safety incidents and they will respond appropriately to national patient safety reports. Safeguarding for children and vulnerable adults – that sounds important for a community pharmacy to be fully aware of.

And you have to complete a patient questionnaire every year. That is actually a bit pathetic – for a business that thrives on the patient experience – it should have been more frequent. I know that some use mystery shoppers so they can sharpen up their act. Any business survives on customer loyalty and experience – I just can’t understand why you all weren’t doing this already.

Everyone is a healthy living pharmacy now. So you all are thinking about the skills and ability of your staff, the state of the premises and how you connect with your community and healthcare colleagues. Sounds sensible to me.

Using summary care records – not sure how you can operate a safe system without using them. And your NHS111 entry is up to date. You are all going to be dementia friendly and if someone is obtaining 6 consecutive relievers for asthma over 6 months you will refer them for an asthma review.

Should have included NUMSAS – it should be core, but we have to be a little patient with technology.

Of course most of you were tittering in the back – easy peasy lemon squeezy.

But now we have the majority of community pharmacies up to a simple standard. Most are now looking in the same direction and thinking the same thing……

What next. Well you are on the Launchpad – flick the switch – turn the boosters on – and head for the stars – and always aim to be better than the minimum that is expected.

 

Community Pharmacy: Living the dream and facing reality

A community pharmacy is an independent contractor of the NHS. I would like to explore that a little more. To me it simply means that you have set up a business and risked your cash and livelihood on the success of that business. It is an important thing – a lot of cash and a lot of risk, but how independent are you and do you think like a business?

Dependency. Perhaps we should really call you and independent dependent community pharmacy, as in reality, most are heavily dependent on the NHS contract. So for many it is the hand that feeds you; the organisation that drives your income and therefore the return on the investment that you have made. Usually when a majority employer says jump – we ask ‘how high’ – we deliver ‘added value’ to that employer to ensure that they ‘keep sweet’. It is not about rolling over, but maintaining an adult relationship. So when that employer issues a ‘white paper’ – the equivalent to saying jump – it is frankly unbelievable to say no. There would usually be some negotiation, some compromise, some hope.

So now that employer is playing hardball and we wonder why? So let’s get the QP done and the NUMSAS and open up sensible lines of communication. Turn this into a learning experience and move on. Perhaps an opening gambit of ‘where do you want community pharmacy to be in two or three years’, ‘how can we work together on this’ even, ‘how about this as an idea’. Letting you all into a little secret – the Pharmacy integration fund – it is supporting those that want to engage – just watch it and wonder whether you could have had that nationally.

Independency. So we have a whole range of minor contracts with individual members of the public. They come in and get a product or a service and put some money in the till. That’s interesting! A business would be asking – ‘do I have enough minor contracts and are these with the right people’, ‘do I fulfil their needs, offer them excellent service, get them talking about me’. Believe me, the safety and security of any business is dependent on the breath of contracts they hold – it is unwise to put all of your eggs in one basket.

I get a little tired about some of the reasons:

  • My customers do not want to pay for things – then you have the wrong customers – find some new ones.
  • My customers do not avail themselves of the services that I offer – do they know about it and are you offering these services to the people that want them
  • I don’t have sufficient footfall – then use a little marketing or go to where the people are.

This is changeable – that is my point – every business thrives when it seeks out new opportunities and new contracts. You are an independent business so think about it and do it.

The state of maternity services – what community pharmacy can do to help

There is little doubt that we are watching maternity services stretched beyond belief. There are 1,400 mistakes being recorded every week. And some of these mistakes are devastating, causing death or severe disability. My heart goes out to the parents and to the staff. It is just not fair.

Surprisingly I note that the Secretary of State, My Jeremy Hunt, ordered an investigation into a cluster of baby deaths. He has put his hand in the Department of Health’s pocket and spent some money – well done Sir. He has also committed the NHS to reducing deaths by 50% by 2030. In a strange way I do hope that he is re-elected and put back in the role to deliver this promise. I have a feeling that he will try his best – that he cares.

However there are small things that we can all do to help. Group B Strep is the commonest cause of infection in the newborn. We saw within the first two cases of the Shrewsbury investigation published in the Daily Mail that they both had Group B Strep infections involved in their cases. It is OK to accept that the National Screening Committee does not recommend a universal screening program. The labs are not ready and there are still questions to answer despite our nearest neighbours in France, Germany and Spain that have such programs in place.

Throughout the UK we now have Healthy Living Pharmacies. I would guess that 90% of English Pharmacies will be successful in achieving the quality payments and being granted healthy living pharmacy status. But what does that mean and what do we want that to mean to our local populations – will it make a difference?

It would help the system if women took charge, knew about Group B Strep, knew their carrier status and if positive received treatment as recommended by NICE and the RCOG. It might mean that two less babies every day would need additional support, one less baby a week would die and one less baby would survive with a disability. It might just take a few babies out of the system – a few babies where you have to rely on the HealthCare Professionals spotting the problem and responding swiftly – a few of the mistakes that cause misery. We have to all work with those fantastic staff in the NHS and help wherever we can.

It will soon be July – its Group B Strep awareness month. The fantastic Group B Strep Support charity will be gearing up for this to raise awareness and encourage women to make a choice. It is important that women know about Group Strep B, understand the small risks and make an active choice, supported by their wider family.

So come on all you healthy living pharmacies – get involved – this is what you have qualified for.

 

Retail Pharmacy

There I have said it. The President said it yesterday, some people seem not to have liked the phrase and I have said it today.

Retail is the process of selling goods and services to customers in small quantities – ie individual transactions and not wholesale.

Selling is a funny thing in the NHS for independent contractors. The GPs are struggling because they can’t sell things; the community pharmacies are struggling because they won’t sell things, the optometrists are struggling because one of their own sell things cheaply and the dentists – well the dentists are doing very well because they sell everything.

Retail seems to be a little like a bad smell – something we turn our noses up to and say that we would rather be ‘community pharmacies’. We are part of the NHS and we only do safe dispensing of medicines. Get real – we are an independent contractor – a stand-alone business with a large, but shrinking contract with the NHS. And incidentally an NHS that does not value our work to the level of previous years and wants us to focus on other things – including retail.

Retail, retail, retail, retail, retail.

It is a bit like an old Tommy Cooper gag – ‘man walks into a pharmacy -…..’ you can make up your own ending from ‘what no prescription’ to ‘thank you for that advice, product, service I feel much better’.

I have tried to explain this before. People buy from a community pharmacy – community pharmacy does not sell to people. So the manufacturer has to pay a fortune in advertising and another fortune to wholesalers and then for planogram placement and then for awareness and training with the forlorn hope that someone will go into the pharmacy and buy it.

Price is what you pay and value is what you get. Sadly the NHS focusses totally on their definition of cost-effectiveness – an acceptable level of effectiveness at the lowest price. People don’t always want to buy cheap – they understand the phrase cost-effectiveness and the fact that you may have to pay a bit more to get increased effectiveness. We are experts in cost-effectiveness and value, are cognoscente of peoples’ budgets and not a slave to cheap. Don’t get me wrong – I am not advocating expensive brands where low cost equivalents are available – it is all about balance.

The community pharmacy that survives will reach out to people – no boundaries – discover their needs – and sell something – whether it is advice, a product or a service. It is a pro-activity that is needed in the pharmacy. On average every pharmacy is responsible for 5,000 residents and passing trade – surely they have a few health needs? The prescription is an aid and a confounder. For example I could have a prescription for asthma and I should think hayfever and eczema and what I could offer to a person with diabetes from their predictable needs. It also doesn’t mean bullying people until they see the error of their ways – it means working with them to consider their health related goals. And please save people from dodgy chat rooms – get them in the pharmacy and give them the right advice.

Heaven forbid that you will have to market your services. It is much better to hide the facts and hope that someone walks in looks around and walks out. They should be flocking in saying ‘I know you do….’. Ah stuff it – stick another poster in the window – that’s marketing. Put a poster saying ‘we do MURs’ – I am sure that plenty of people will come in and ask for one of those.

What are we trying to create? Every Pharmacy should be a professional, clinical, retail, healthcare, environment. It should have the look and feel of a GP practice. Don’t say ‘come into my converted broom cupboard – don’t mind the crates we have just had a delivery’. Say ‘come into my spacious, rather beautiful clinical room with a few bits of kit that makes me look like the professional that I really am’.

Am I shallow thinking that it is all about image? Of course – it may just be me that wants to walk into a clean and bright pharmacy, invited into a professional looking consulting room with the phrase ‘the pharmacist will see you now’, find a professional looking pharmacist who smiles and tells me their name.

In conclusion ‘retail’ isn’t our bogey word – it is our saviour. Embrace it and start doing it properly.