Partnership in immunisation

A GP and a community pharmacist were sitting in the coffee shop – well sitting in the bar would sound like the start to a joke.

The GP says – “you know I hate flu immunisation. We have so many to do the practice is absolutely full; they are expanding the numbers all the time, then moan when we don’t surpass the targets. We have to put on extra clinics and are even thinking about opening at the weekend – but with all the overheads we are hardly likely to break even”.

The Pharmacist says – “Ha – I hate Saturday afternoon and Sunday. We are open and you are closed, it is hardly worth it for me, but it is part of my contract”.

A lightbulb moment!

“How about running the additional flu clinic in the pharmacy. You book patients in on a Saturday and Sunday. Double book them and your nurse and the duty pharmacist can alternate patients so we both make some money”.

“Hmm”, smiled the GP, “and I wouldn’t need to open up”.

“No, and while the patients are waiting they might get some advice on other common conditions or even buy something”.

“Sounds like a good arrangement to me”, Agreed the GP. However, last year one of the practice nurses had an accident and went sick, if it happens again could you help me out?”

“OK – I have three pharmacists that work for me, I am sure I can arrange for one to do some of your clinics if you cover their costs”.

 

Now why doesn’t it work like this everywhere?

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Health vs Illness

I had an interesting discussion with a GP. How do we differentiate General Practice and Community Pharmacy in a patient’s mind? It is not easy when the services delivered in community pharmacy are variable. The politics are also variable – we are told to visit community pharmacy for common ailments and then we are warned about cancer and told to see a GP.

So I said – it all depends on whether you are healthy or ill. If you are essentially healthy you should visit the pharmacy and if you are ill, you visit the GP. In the backroom you join them together and then you create a compatible contract with elements of profit share and joined records.

So when do you visit the pharmacy and what services should they provide. Think about it – when you are essentially healthy you go to the pharmacy. This might mean:

  • Common minor conditions
  • Routine immunisation
  • Travel health
  • Obesity, smoking and exercise management
  • Emergency hormonal contraceptives and general contraceptive services
  • Child health

‘Hold on a minute – all immunisations’ – yes these patients are not ill and the whole point is to tell patient to only go to their GPs when they are ill – really ill and the GP practice will look after them. When you are not ill then you go elsewhere – to the pharmacy.

You aren’t ill when you need a contraceptive – you aren’t ill when you go on holiday and children aren’t ill.

‘But how would you deliver this’. Community pharmacy can employ nurses if that is appropriate or use pharmacists. We are well used to this mix of staff delivering good care. It would just need the contracts to force working together with some cross management of resource.

‘What do you mean – cross management of resource?’ The community pharmacy may contract nurse support from you and you may contract pharmacist support from them. When you both have access to the medical records, it matters less where you practice and operate the services.

‘But will we lose money?’ That is the whole point of shared contracts – so the delivery becomes a shared responsibility and you are jointly paid for delivering outcomes. It is not beyond us to develop something like this is it?

The whole point is that we have to simplify the message to the population in a manner that they can understand. If you are ill go to the GP, if you are generally well then see the pharmacist.

Community Pharmacy – time to change?

Is it still now or never – or has the rush passed and are we still calling to action? All I know is that we have to think differently in community pharmacy. We are where we are, some might say, but it is neither where we want to be nor what the population or the NHS wants from us.

So let’s start with the negatives. We have a community pharmacy contract that is dispensing focussed. The DH believes that there are too many pharmacies and that dispensing is not economical. The provision of clinical services is hugely variable in volume and in quality and we are losing our way. There is money in the system, but it is not going to flow in a manner where it could end up in owners’ pockets. The politicians are not confused as to the role that they want community pharmacists to play in the future, but they can’t see a path.

And the positives. The government seem hell bent on driving patients to the pharmacy before booking an appointment with the GP or out of hours provider. Areas have built new services against the trend and many community pharmacists are providing services that are above and beyond our basic expectation. Community Pharmacists are engaging more, but are still a way from building integrated multi-professional services within primary care other than in PM Challenge Bid Projects. The government will invest in pharmacists to support primary care or at least in GP practices.

One sad fact always comes to mind. A procurement pharmacist in a multiple can make more money for the company in one trade than a whole team of clinical specialists over the year. Remember this as this is important.

If there is little new money, then it may be about trading and compromise, working towards a new definition of community pharmacy that suites the population, the government, the profession and the owners. Perhaps the owners are the key to change – have we understood this?

So what are we going to do about dispensing? Here is just one suggestion. We split prescriptions into acute/first or repeat – it is easy to do. We slightly increase the dispensing fee of all acute/first prescriptions and reduce significantly the fee for all repeat prescriptions. The money saved goes into two separate pots. The first is an establishment payment that supports any pharmacy to upgrade to a ‘Healthy Living Pharmacy’ or ‘Self Care Pharmacy’ – I don’t care which, but these pharmacies have additional features and additional standard services. We can bundle ‘Pharmacy First’ or MASchemes into this, along with staffing and training requirements. The second is a clinical services pot which supports the pharmacies becoming a clinical service point within the system – it might only need to be a pump-priming fund and could sit under the control of the Chief Pharmacist. No more dabbling in asthma or pain management – a fund that can support pharmacists to develop and deliver specialities in the pharmacy.

Yes it is about a choice – repeat dispensing will be less profitable and factories may take a larger role – but community pharmacies have the chance to develop and provide additional services. And yes CCGs and LAs that already invest in community pharmacies must embrace this move and we work out how their commitment is rewarded. A community pharmacy must be able to survive dispensing fewer repeat prescriptions (or sending them to a factory) and increased clinical services.

Community pharmacy also needs to think independently and locally. Joining as members of federations they can play an active role in the delivery of multi-professional providers within primary care. Through this route, community pharmacists will bid alongside GPs, Optometrists, Dentists, Community Service providers and the voluntary and charitable sectors for contracts. This is the way forward and if it doesn’t work then hospitals will take it over (whatever that will mean).

I am hearing that the multiples are split – some see that dispensing is their future and some see that clinical services hold the key. That’s fine – there is room for both views and perhaps, in the future, owners will be able to make a choice, knowing that both can thrive.

Message to General Practice – come and get me!

This is a simple message from us clinical pharmacists to all you GPs out there.

When you are looking to make a change in your practice, when a partner leaves, a nurse retires or you don’t feel that you can afford the current locum or salaried GP rates – come and talk to me.

I am a pharmacist – I have additional clinical qualifications to pharmacy and have spent most of my life working with patients, their conditions and their medicines. I am logical and organised – almost to a fault – and like you am used to working within a very busy team where we all throw our efforts together. OK – I may ‘think’ I know more than you about medicines, but you are streets ahead of me on other areas. I may need lots of help, but it may all be mutually beneficial.

If you would like me to – I can join your practice as an employee and do the following:

  • Manage your repeat prescribing system and deal with all the queries (implement electronic prescription management)
  • Handle all of the clinic letters and discharge letters
  • Review your patients who are on complex medicines
  • Help deliver your QoF, LES and DES services
  • Ensure that the whole practice knows the systems that are in place and about new medicines and guidelines etc
  • Work with the CQC inspectors who are asking about medicines management and ensure your practice passes this aspect of their inspection

To me, this is all quite simple. I know plenty of fairly young pharmacists who are already doing this. However, I could also do the following:

  • See some of your patients with common conditions who present at your practice, offering routine and emergency appointments – a bit like a nurse practitioner
  • Work with a specified GP and your practice nurse to manage long term condition patients. I have done hypertension, cardiovascular risk, respiratory (asthma and COPD) and diabetes clinics before, a bit of complex pain management, ostomy and wound care (I learnt pressure bandaging at St Georges’ in the day)
  • Run your anticoagulant service and other near patient testing services – I even do dopplers and recommend on post DVT management
  • I will even roll my sleeves up and do some vaccination clinics

Where I am yet to train as an independent prescriber, you can help me with this, although many of my colleagues are already independent prescribers. I know my limitations, accept my responsibilities and can work effectively with colleagues in a team.

If you would like to talk to a pharmacist already working in a GP practice or to the GPs that have employed them – please let me know – there are some cracking good examples around – one that might win an HSJ award next week!

If, unfortunately I am not able to join you, it is estimated that several thousand of my pharmacist colleagues will be available over the next few years – strictly on a first come first served basis.

On the other hand – you could always work harder or close

The Community Pharmacy Challenge

So here is my challenge. A simple challenge given to me at a meeting. A flip chart where someone drew two circles – one general practice and one hospital based care – primary and secondary care they said and smiled. They asked – where does community pharmacy fit – and handed me the pen.

This is simple I said and drew three additional circles on the page:

 

The first circle sat far away from the others. Community pharmacy sits outside the others as a completely separate entity from the traditional NHS. It represents the first port of call for much of the population. It provides a simple contact point for people to get health and well being advice, pharmacy first services for common conditions and a wide range of public health services including simple screening for cancer. It is of vital importance in empowering people to look after themselves without needing to access the ‘NHS’ – an early gatekeeper. There remains a lot to do to make this a reality as it is a bit piecemeal at the moment.

 

The second circle sat next to general practice, but not overlapping. Community pharmacy is an alternative service provider to patients. Some patients may choose to have elements of their care delivered within a pharmacy. It is not difficult to see joint registration and full sharing of medical notes to support this. I have blogged before that I would like to see community pharmacy have a bigger role in managing GI complaints, contraception, asthma, immunisation and skin conditions. We can make this happen and when services are offered to AQP, community pharmacists should be prepared and ready to offer patients choice. It doesn’t usurp General Practice – it sits neatly beside.

 

The third circle overlapped General Practice and I sneaked in a few more – dentists, optometrists, community services, social care, charities, voluntary services and housing. And drew a large circle around all of them. This is the new definition of primary care – where we integrate these and other local services (sorry to the loads that I have missed out) where everything comes together to look after people with complex issues. Of course I mean those who are old, but we must recognise that many conditions are not solvable with a pill and everyone needs to work together.

 

With a gentle smile I put the pen down and fielded questions. So where do we start?

 

That is very simple. I can do the first today and there are some great examples around and a huge need within the whole system for this to happen. We must start to manage demand as a matter of importance. We need to think differently about the profile of community pharmacists and work on patient perception. A simple start would be for all clinicians to ask ‘what did the pharmacist say’.

 

I can do the second next – it will need a little training, but there are examples of contracts and consultant/specialist pharmacists out there. We must plan to expand capacity without creating additional pressure on the system.

 

And the third – the golden ticket might take a little longer. There is a lot to do to redefine primary care and deliver it. Working together takes visionary and charismatic leadership, giving all parts a seat at the table, sharing problems and creating solutions that work. Some of the elements of this jigsaw don’t even recognise the pieces, let alone have an understanding of what can be achieved. But we have to start somewhere – it’s now or never.

 

Simple!

What Pharmacists Want?

I have often wondered what pharmacists want? The things that would make a real change to the way that the population views community pharmacy and what would make community pharmacists change? I have blogged about Independent Community Pharmacist Prescriber (limited) a couple of times before. Community pharmacists must have proper access to medicines to enable them to do their job properly. I appreciate that PGDs are there and they can be employed to deliver a service.

But it is not the same. There is nothing like the power of a prescription to change the public’s view on the ability of the community pharmacist to manage conditions. In my opinion, it is a game changer of the greatest order for community pharmacists.

There are some similarities between general practice and community practice. Both are located within communities and considered important functions. Both are run by healthcare professionals respected by their communities. Both have private consulting rooms where people can get advice in a confidential manner. When it comes to providing treatment, the GP can give a prescription, but the community pharmacist has to sell it (or supply it if on a PGD).

I also understand that full independent prescribing is the way to go. It is for some, but it requires a considerable effort. I recently spoke to a senior pharmacist in a large multiple and he simply said ‘I’ll create as many IP pharmacists that are needed to deliver contracts’ – so that is none then! I could wait for the plethora of new contracts that require IP pharmacists in community pharmacy, but I can’t see them coming yet.

I understand that we need to manage training and governance, but they can be overcome. There are also precedents that are set within the NHS that support this process.

Do pharmacists want a prescription pad so they can prescribe medicines from a limited list to patients following a consultation. Many pharmacists have already been trained in common condition treatment and stop smoking treatments and supply medicines through PGDs. Training requirements may be quite small. But I do believe that giving a prescription will save both time and paperwork and the CCG/NHSE will be able to easily see what is prescribed through PACT data.

The response so far from the profession has been mixed. Some of the RPS English national board members were ‘interested’ and some were ‘supportive’. Others, including groups that represent the interest of community pharmacist have kept their powder dry. In fact it all seems quiet on the subject.

So – I have spoken to Oliver Colville and he has approached Lord Howe. I have written to my MP asking for his support and he has also written to Lord Howe. The ball is rolling. I am waiting for the statement from pharmacy organisations, I am waiting for the letters to flow into MPs, and I am waiting for the petitions.

So do pharmacists know what they want? Do they want to have a prescription pad and be able to prescribe medicines within their usual practice? Will they ask for what they want?

I will be able to answer that question very shortly.

Pharmacy game changers

The future is rosy – said the Minister responsible for Pharmacy. But what are the small changes that might make a real difference to the profession and the way that pharmacy operates. Here are a few suggestions:

  • Co-registration – patients should be able to co-register with a community pharmacy of their choice in which a nominated pharmacist becomes jointly responsible with their care in association with the GP practice. It is a simple concept – know your GP and know your pharmacist. Registration would open up the better inclusion in NHS Choices, the identification of expertise and services and the sharing of clinical responsibilities.
  • Access to medicines – the main routes for pharmacists to supply/prescribe medicines to patients is limited and restrictive. PGDs are a lot of work and qualifying to become an independent prescriber a lot of hassle to find so few opportunities in community pharmacy to use the skills. I have long advocated a new legal category of independent community pharmacist prescriber (limited) which might allow thousands of community pharmacists to prescribe from a limited range of medicines in the course of their practice. A community pharmacist with a prescription pad (albeit a limited list) could be important in the mind of a patient.
  • Access to technology – I appreciate the need for pharmacists to have access to some further information about patients and the commitment from the Secretary of State to make this happen. However, in the first instance I would like to see the ability of the community pharmacist to book an urgent appointment for a patient, particularly outside the normal opening hours of the practice. I would also like to see commissioned extended opening hours pharmacies having the ability to support teleconsultation with the doctor on call.
  • Underwriting and support of emergency supply – many patients don’t know that there is a provision for emergency supply of medicines. Scotland operates a PGD for this purpose and at least one CCG has agreed to pay for medicines issued in this way. One other CCG has specific arrangements around the emergency supply of blood testing equipment. Underwriting the supply of medicines is a small commitment for CCGs to will make this route of supply simpler.
  • Co-operative ventures. Like Elvis, most pharmacists are ‘taking care of business’. But several pharmacies have linked together in some way. There is a need for Pharmacists and Pharmacies to visualise a different way of working, perhaps in federations or partnerships to ensure that their interests are properly represented locally. In my opinion there is often a gap between pharmacies, pharmacists and the local commissioners. I appreciate that there are a number of representative bodies in this area, but there remains a need to drive and support delivery as well.
  • The Royal Pharmaceutical Society – I may have been critical in the past, but I am changing my view. The team seems stronger and are clearly turning their attention away from quasi-regulation to true representation. There are some strong and dedicated people there and when someone in a senior position says less standards more stance – well I am impressed. They are well on the way of creating a credible Royal College – a suitable amount of general sucking up to start with – but now moving with incredible speed and engagement. I would like to see Dave using a JFK quote – ‘my fellow pharmacists ask not what the profession can do for you, but what you can do for the profession’.  Time to stand up and be counted – it’s now or never.
  • Sharing innovative practice. I often dream of the world that I want pharmacy to be. The annoying thing is that someone is already there. I am constantly staggered by the extent and quality of service that pharmacists provide. I am constantly disappointed that these examples are not led right across England. I don’t know why this is! Are we too analytical – do we believe you can’t talk about anything until you have ‘evidence’? Hoisted by our own rope perhaps? In all my years in the NHS, I have seen major structural change and service development, based on a flimsy ideology and a corrupted understanding of the problem that needs to be solved. Pharmacy needs a step change in the way we advocate pharmacy service development. Pragmatism and drive, rather than hope and a vision. I remember Judith Smith’s quip – ‘Pharmacy has had more visions than the Old Testament’ followed by it’s now or never and JDI.
  • My name is…- this is a significant drive in the NHS. Years in hospital clinical pharmacy practice I emphasised the need to introduce yourself to the patient in the bed watching faces going past – My name is… I am responsible for…. You can ask me….. It takes the conversation and the relationship to a personal level. I often hear someone saying – can I speak with the pharmacist? Every pharmacist should respond with – My name is…. The next pharmacist responds – My name is… I am part of the Pharmacist team here. Every member of the team should introduce themselves by name – the pharmacist has absolutely no excuse. The best already do this effortlessly.
  • Showing that you care. A very wise pharmacist said to me – ‘they don’t care what you know – until they know that you care’. I don’t know where this quote comes from or whether he made it up himself, but 30 years on it is still in my mind.
  • Confidence. I don’t know whether any of this is true, but in a way it doesn’t matter – it is what we believe. Pharmacists belong to the third largest healthcare profession. In a week more people interact with a pharmacist than all other healthcare professions combined. Pharmacists can offer a solution or be the base for the solution to many of the issues currently facing the health and wellbeing of the population.
  • Building on relationships. So many other health professionals say nice things about pharmacists and pharmacy services. So many leaders throughout the NHS suspect or believe that pharmacists and pharmacies are part of the solution. Please don’t just accept this – think how this belief can be channelled and expanded.

I am sure that you can think of other small structural, procedural, legal and emotional changes that could add up to significant change

Pharmacy game changers

I recently wrote a blog called ‘Dispensing on the Titanic’. It was intended to be thought provoking with a heavy negative followed by some positives. If you haven’t read it, please do and see what type of Pharmacist you are.

I have had quite a few responses after posting the blog, from the 500 or so people who have read it. Here is how I have segregated the responses:

Ostrich. It is surprising how many Pharmacists believe that dispensing is their only USP. Without it they are lost. They feel that the profession should hang every element of the clinical service that they provide around the dispensing and supply function. You may think that the government pays Pharmacies for dispensing, but that would be foolish – they pay Pharmacy to hold back the cost of medicines – that has always been their objective and Pharmacists have been very good at it. Unfortunately the growth in the number of pharmacies has made this less economic and dispensing factories which could be ‘more economic’ than individual pharmacies are coming along. Unfortunately this still represents the core of the contract and the core income for pharmacies.

Heroic. I always agree with Pharmacists who say that their patients love them. They feel that the public will get out there and fight closures. In my opinion this is misguided. Many community pharmacies are small businesses. When things get tough they don’t try to drive revenue, they cut overheads and actually reduce services. The accountant worries about cash flow and the business stops functioning and goes into liquidation. The day to worry is when the ‘big boys’ sell off the unprofitable branches and they can’t find a buyer. And it has already happened. A community pharmacy is not an A&E – I have no evidence that a closing pharmacy can attract a midnight vigil of 1,000 local residents led by the local MP.

Progressive. I was stunned by just one pharmacist who asked ‘so what are the drivers and levers for change’. The question was spot on and I have to say that it came from a relatively young pharmacist (although most of you are young compared to me now). The Pharmacy profession has been ‘at the crossroads’ for so many years that I almost feel sick when another leader uses the term. The RPS commission report was called ‘Now or Never’ – it could have been called ‘broken down at the crossroads’ – or my preference ‘FFS’.

There is a small number of Pharmacists who seen to recognise that we must do something bold and now. This comment stood out amongst a number of suggestions – some a bit wild and wacky and some very sensible and reasonable. I wouldn’t throw any of them away – we must be radical to make things happen. It might be the time for some ‘blue sky’ or ‘out of the box’ thinking. I am up for that as long as it creates some forward movement.

The Future. The future is what the profession makes it. The question that I leave you with is what are the levers and drivers. In all games I watch there was one shot, one pass, one move that created an unstoppable play – the game changer. So what are the game changing moves for community pharmacy and the pharmacy profession? Which ones can be quick and simple to explain and which ones will take longer and perhaps need legislation.

I am thinking about them; I am talking about them. Are you?

Dispensing on the Titanic

Today the RPS funded Commission launched it future models of care document and the RPS ENB gave its strongest commitment to support the interests of pharmacists. I have to say that David gave a closing speech that was delivered with sincerity, believing the commitment that he was making. I know he will really try.

I loved Judith’s quip that pharmacy has had more ‘visions’ than in the Old Testament, her view that the window of opportunity was now, the naming of the document ‘Now or Never’ and her plea to ‘just do it’.

It was Stephen Dorrell MP that asked the audience – ‘which group of healthcare professionals see more people each week than all the rest put together’. Really – even I hadn’t used this statistic before – something to be think about with pride.

I was chatting to Nick Kaye – he is always an inspiration – a clear ‘can do’ pharmacist, but it is undoubtedly the time for all the profession to do.

There were, however, some things that were not said. Dispensing is dying, the contract is a disaster and the government, DH, NHS England, Uncle Tom Cobley and all agree. I reflect that dispensing has changed. The need for pharmaceutical compounding skills is gone – we no longer make much and measuring out water to make up an antibiotic mixture is as complex as it gets. Let’s be honest – we put labels on original containers. The clever and important bit is the patient interface before and after the dispensing.

Keith is clearly right. There is now a clear and growing view that the dispensing element is not considered good value for money. Community Pharmacy has saved millions of pounds for the NHS through good procurement, but it is not enough. The government feels that big business will bring in automation and additional discounts through purchasing power which would be reflected in increases in the National Average Discount Rate and money will come rolling back into the coffers. I am not sure that I agree with them, but that is hardly likely to matter – it is an iceberg coming our way. They might even consider putting dispensing out to tender when the electronic transfer of prescriptions is routine. And the vultures are circling.

It’s like dispensing on the Titanic. It is sinking and we are still playing. Bright new pharmacists are drowning under the pressures and are not realising their aspirations. So Captain Smith is saying it’s Now or Never – just do it! Now that is a strange coincidence isn’t it!

Where Keith is wrong is saying that there are 3,000 too many pharmacies and we should go back to earlier days. This is assuming that pharmacies are only there to dispense. Pharmacists are much more than dispensing. Pharmacy technicians are much more than dispensing. Pharmacies and the whole team are much more than dispensing.

We actually have a strong and vibrant network of pharmacies. The old rivals of multiples and independents are working together, led by visionary pharmacists. There is a real opportunity to link up groups of pharmacies with groups / federations of GP practices and look to solve local community issues. All primary care contracts are a disaster – we must show NHS England how we can work together so they can align the contracts to facilitate progress. Heaven knows, they can’t do it on their own – we have to show them the way – lead by example.

Let’s look at people who want pharmacists and pharmacy owners to step up and solve the problems:

  • Jeremy Hunt needs to solve the A&E crisis. He has thrown some cash at it, but he knows that he has to manage demand. Only community pharmacy can change the flow of patients to A&E and prevent the swamping of General Practice. Common condition services with proper access to medicines and technology support is the answer. Don’t complain about 100 hour pharmacies, they are the solution to out of hours care
  • Professor Kevin Fenton said that he would like to see 5 new services (public health based – non-transmissible disease related) in community pharmacy within the next 5 years. Too slow Kevin – people are dying – let’s do it quicker
  • Sexually transmitted diseases, safe sex advice, emergency hormonal contraception, contraception, services for women and children – where else, but in the community pharmacy – local, discrete and effective.
  • Duncan Selby looked disappointed hearing that there were so few healthy living pharmacies – I think he hoped I would say 5,000 – if you want more just ask
  • Jane Cummins pledged further action to protect patient safety. With 1,700,000 serious prescribing errors each year, the failings of care homes – surely she will turn to pharmacists to help.
  • Dr Mike Berwick says we are not doing enough for the 15m people in England with long term conditions. If there are real problem in medicines selection and adherence – think pharmacist – just saying. Even Paul Dinkin in monitor said that skill mix was the answer
  • Patient organisations, such as Diabetes UK who spoke at the launch today all say that their members value the advice and support that community pharmacists offer – pharmacists change lives – tell your MP.
  • National Voices talk about supported self-care. Who is better positioned to help you with this agenda?

I can’t wait for the community pharmacist and the pharmacy technician to remove the chains that keep them in the dispensary.

So national frameworks, area implementation and local flexibility is the answer. If we remove the problem, perhaps everyone will see community pharmacy as the solution.

 

Community Pharmacy co-operatives in Primary Care

Community Pharmacies must start to think in a co-operative way. This is the way to encourage change. Change that delivers better outcomes for the local communities.

Primary care is mainly built with independent contractors. In fact four groups of independent contractors operate within this arena. You could mix in here a community services provider, a mental health provider and a social care provider. And add a little police and ambulance and fire services, some housing and education with a whole host more. Well that is what makes up community based public services. The contracts are all set up individually which creates isolation, competitive behaviour and gaps between services for people to fall between.

It has to stop! We have to start to think in a more joined up manner which starts with the community at the heart and builds the services around in a joined up manner.

I am seeing GP practices forming co-operatives. One in Brent provides services for approximately 80,000 people. The co-operative are able to provide a greater range of services, sharing both management and clinical skills and experience across the group. The sharing is important for them to all improve to a level and move forward consistently providing a quality service to their community.

As a guess there would be 10 community pharmacies that are within the boundaries of the co-operative. A further guess would say 5 independent or small chains and 5 from the multiples. I could add 6 dentists and a further 6 optometrists, but that would add a further layer of complication for today.

Would the 10 community pharmacies form a parallel co-operative and create a memorandum of understanding? Would they get around the table as a ‘team’? And would they discuss the needs of the local community with the local community to work out how they could better work together as a group and as an important part of a larger initiative? And would companies change their ways of working to support this?

I was going to focus on the multiples, but I suspect that the independents won’t find this easy either. It requires some fundamental changes in the way that Pharmacies are run.

  • Co-operatives must form a general working structure that allows them to meet with and work with other local service providers
  • Pharmacists, usually managers rather than owners, must be empowered and supported to negotiate local working arrangements and service development.
  • Pharmacists must be supported to develop local services within the joint co-operatives either in tandem with or instead of national company driven services
  • Companies must find ways of supporting and incentivising stability within a single location

Members of that community will begin to see that they have not 10 access points for healthcare, but 20 and services that might be offered by a few can now be offered by all. With co-ordination and information sharing it might just look seamless. MURs and common complaint services can link across practices and pharmacists can join in late night and out of hours provision. A wider range of public health services would be more efficient if fully linked up with GP practices.

This might seem a big hurdle, but to get 10 GP practices and 10 community pharmacies working closely together in a single community will be a great start and an example to encourage other providers to join together.