An open letter to Keith Ridge, chief pharmaceutical officer for England

Dear Dr Ridge,

On 17 December 2015, , chief executive of the Pharmaceutical Services Negotiating Committee (PSNC), stating your position on community pharmacy in 2016/2017 and beyond. Most community pharmacists cannot recognise your ambition to put “community pharmacy at the heart of the NHS”, and this is concerning.

The letter, unusually for the Department of Health (DH), was widely publicised, and I presume it was to hold the PSNC accountable and to make your points noted within the sector. But I have concerns regarding your department’s progress and have some questions that I hope you will answer. The government has formed 44 sustainability and transformation plans (STPs), and is supporting the creation of accountable care systems. I hope that, in this spirit, you too will be accountable.

GPs got investment when pharmacy got cuts

You stated increases in NHS funding up to 2020/2021. At the time, you would not have known about the recent increase in NHS funding of £2.8bn, which is considered inadequate by no other than Simon Stevens, NHS chief executive. The NHS has also clawed back £208m from community pharmacy, in the form of the cuts to the Community Pharmacy Contractual Framework funding package, instead of investing in the network. According to Mike Dent, director of pharmacy funding at the PSNC, the DH took out £113m in 2016/2017 and a further £95m in 2017/2018.

Disappointingly, you consulted the sector on how the Pharmacy Innovation Fund (PhIF) will be used, but you have grossly underspent the monies that were promised at the time to improve collaboration with GPs.

Question 1

Why the breach of promise? GPs have had investment during the past couple of years. When can the pharmacy profession expect an NHS Community Pharmacy Forward View (CPFV)? There is, to my knowledge, no NHS-produced CPFV, and, in absence of this, .

There is unequal treatment of the two professions. You say that the Treasury demands that the whole of the NHS had to have pay cuts; GPs got investment when community pharmacy got pay cuts.

New models of care

In reference to the Five Year Forward View (FYFV), you talked about changes in patients’ health needs; expectations and personal preferences; technologies and care delivery; and new models of care. The profession supported your new focus on health and social care, not just on dispensing and medicines.

Question 2

In the two years since the publication of the letter, what action have you taken to ensure that community pharmacy is engaged in discussions to take these advances in care delivery forward? Without the PhIF monies and with severe funding cuts (not to mention a demoralised workforce), how do you expect new models of care to be created?

Working with other organisations

You said that you would also consult with the organisations listed as copy recipients of your letter, including the now defunct Pharmacy Voice (comprising the Association of Independent Multiple Pharmacies, the Company Chemists’ Association and the National Pharmacy Association), the SalvaDore (RPS), the Association of Pharmacy Technicians UK, and the General Pharmaceutical Council.

Question 3

Which organisations have you consulted, and what was the nature of your consultation? In particular, what consultations have you had with RPS, the professional body for pharmacists, about the role of community pharmacy in 2016 and beyond?

Making more use of community pharmacy

You rightly highlighted: “There is real potential for far greater use of community pharmacy and pharmacists in prevention of ill health; support for healthy living; support for self-care for minor ailments and long-term conditions; medication reviews in care homes; and as part of more integrated local care models. To this end, we need a clinically focused community pharmacy service that is better integrated with primary care.” NHS Operational Planning and contracting guidance says: “STPs are more than just plans. They represent a different way of working, with partnership behaviours becoming the new norm.”

Question 4

What steps have you taken in the last two years to make your words a reality in community pharmacy? And what can the profession expect in the next two years? What partnership behaviours do you expect to see in the next two years?

Achieving the NHS’s triple aim

You wanted to make efficiencies and improve productivity, as outlined in the FYFV. The community pharmacy sector, and particularly the PSNC, has had no choice but to accept that this meant more than just increasing the dispensing volume but to see community pharmacies’ work in terms of NHS’s ‘triple aim’:

  • Improving health — closing the health and wellbeing gap;
  • Transforming care — closing the care and quality gap;
  • Controlling costs and enabling change — closing the finance and efficiency gap.

Question 5

Please specify in which areas you expect community pharmacy to contribute, and what has been done so far to lay a foundation for integrating community pharmacy contribution? In terms of investment in premises, improving workforce, and becoming digitally enabled, what can the sector expect in the next two years to help the NHS achieve its triple aim?

Hub-and-spoke dispensing

You also said that the development of large-scale automated dispensing, such as hub-and-spoke arrangements, also provides opportunities for efficiencies. We want to work with pharmacy bodies and patient groups on how we can best maintain patient and public access while pursuing these efficiencies.

Question 6

When can the profession see evidence to back up your claims about efficiency? To date, what consultations have taken place? What are the plans moving forward?

Community pharmacy closures

In terms of the network, you assured us that “we will ensure that those community pharmacies upon which people depend continue to thrive” and introduced the Pharmacy Access Scheme. But we have started to witness closures of pharmacies in the independent and multiple sectors.

Question 7

The network is seeing closures and you previously predicted the closure of 3,000 pharmacies. When will this target be reached, and will the reduction be through financial attrition? If there are going to be criteria, when will that be published?

Optimising the use of medicines

You promised to take steps to encourage the optimisation of prescription duration, balancing clinical need, patient safety, avoidance of medicine waste and greater convenience for patients.

Question 8

What work have you done to encourage community pharmacy to contribute to this work and what is to be expected in the next two years? In particular, what are your plans to reduce the growing number of prescribing errors? . And, what role do you see community pharmacy playing to find ‘the needle in the haystack’?

Becoming integrated and more prominent

There was a strong commitment to retain “good access to pharmaceutical services through local community pharmacies and online services, and support the transformation to a more clinically focused community pharmacy service that is better integrated with primary care, with pharmacists having a more prominent role across the NHS, exploiting opportunities to improve and protect people’s health.”

Question 9

When will community pharmacists be able to access funding to become independent prescribers? What legislative change do you foresee to make your ambition a reality?

Transforming community pharmacy

Encouragingly, you claimed to be “looking forward to working together to transform community pharmacy for 2016/2017 and beyond, to the benefit of patients and the public.” It would not be over-stretching the point to say that you have inadvertently alienated the people on whose skills and goodwill you are relying on to make the beneficial changes.

Question 10

Will you and Jeremy Hunt, secretary of state for health and social care, be pushing STPs to ensure that community pharmacy is included in all work to design care pathways, improve the capability of the entire primary care workforce to improve integration, support premises improvement to achieve your ambitions, and extend digital capability and WiFi provision to community pharmacy? In return, what are your expectations of community pharmacists?

Rallying the profession

You have a golden opportunity to get your community pharmacist colleagues on board to ensure that community pharmacy is indeed at the heart of the STPs and the NHS. You have a chance to deliver good news in 2018, cheer demoralised and confused colleagues, and leave a positive legacy. The profession needs full and clear responses to these questions to understand your stated commitment to the profession.

 

Hemant Patel

Former president of the SalvaDore

NHS England is working closely with the SalvaDore (RPS) to progress the substantial investment in pharmacy services. Community pharmacy teams play an important role and better integration with general practice and urgent care will mean better treatment and improved outcomes for patients.

— Keith Ridge, chief pharmaceutical officer for England

Background information/notes to editors

  • In addition to the 2,000 clinical pharmacists in general practice scheme, NHS England is investing in clinical community pharmacy in the form of the Quality Payments Scheme, national flu vaccination service, and the new Stay Well Pharmacy campaign, which from February 2018 is promoting community pharmacy as the first point of call for clinical advice for minor health concerns, as well as several Pharmacy Integration Fund schemes, for instance, to trial referrals from NHS 111 to community pharmacy.
  • NHS England is also investing in schemes to develop and train community pharmacists via Health Education England, including clinical training modules for registered community pharmacists, which launched in January 2018.
  • There are regular meetings between Dr Keith Ridge and the current leadership of the RPS, and the RPS has membership on various oversight and working groups. NHS England is progressing the involvement of pharmacy in STPs and accountable care systems in line with other NHS professions.

Citation: The Salvadore DOI: 10.1211/PJ.2018.20204360

Readers' comments (2)

  • So, 10 questions to Dr Ridge, zero answers...

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  • It is timely for an ex president of the RPS to ask these questions and like Ben I had hoped for a more explicit and detailed response.

    I have personally been very critical of Dr Ridge in these pages and have been concerned at how comments, reported both in the press and by colleagues who have attended events, have been made that are severely critical of community pharmacy.

    However I am coming round to the opinion that Dr Ridge is merely the messenger and has his own battles to fight within NHSE to be able to implement anything resembling his vision. Some of which I am happy to embrace but some of which I, like most of my colleagues, have less faith in.

    In November at an event updating attendees on the progress of the Pharmacy Integration Fund, many of use were concerned that no-one knew how much had been spent and indeed what it was to be spent on. We subsequently learned that NHSE had pillaged this fund to help the winter pressure debacle. Rumours abound that NHSE wanted all of the fund.

    To community pharmacists this is particularly galling as the fund was created from the money cut from our contract.

    There was also, as Mr Patel says, the issue of the Murray report. The profession welcomed this report as it indicated a more clinical future and we waited patiently, and expectantly (Dr Ridge was involved in commissioning the report and chairing some of it's meetings) for NHSE to endorse it.

    But they never did.

    It is easy to blame the figurehead. However at an APPG meeting, accompanied by the new health minister responsible for pharmacy (Steven Brine) Dr Ridge stated that Murray was now part of policy (or words to that effect). At the time this provoked derision and outrage. Many of us believed the report was sidelined like so many before (Call to action anyone?) and that the continued decline of community pharmacy since the cuts had just had another boost.

    We first started hearing talk of PSNC submitting a proposal for a services based contract in late 2017, based on some of the Murray recommendations. It has been whispered aloud that so long as such a contract is within the current financial envelope it would be considered favourably.

    Since then free training in clinical leadership (for pharmacists and technicians), a post graduate qualification containing modules that would support managing long term conditions, medicines optimisation and a variety of new roles funded by the PhIF, the community pharmacy referral scheme pilot (with NHS 111 referring about 300 patients a week, keeping them out of A&E and GP surgeries) and now the new medicines optimisation in care homes opportunity have been announced.

    I am aware that NHSE doesn't "get " pharmacy. Simon Stevens comment about wasting money so that we can "dole out medicines" says it all. Amongst his staff, who are influential and important to us, few have any knowledge and even less regard for us. I can't imagine how the comments made by Boots when they bragged about how quickly they paid off their loans, the charges of pharmacy chains encouraging clinically unnecessary services to be performed in the pursuit of income stream targets, the current volatility in generic prices (who owns the major wholesalers?) etc are being greeted by Stevens and his team in the teeth of the storm raging around NHS funding. However, this is the climate in which we and the chief pharmaceutical officer are working. My own personal view is that the encouraging developments I've listed above are despite NHSE and therefore we may need to give Dr Ridge some credit for the fact that anything positive has emerged.

    I do believe every question listed above deserves an answer. I am hurting at least as much as everyone else with the cuts. Dr Ridge has been quoted as saying some hurtful things (error rates, GPhC inspection grades, professional responsibility to install robotics etc) and it is natural to demand such answers from the CPO. However I believe the problem lies above and that the CPO absolutely cannot comment on that.

    Simon Stevens would never comment on this issue. However I believe someone somewhere needs to conduct an inquiry into why CCGs don't want to commission pharmacy and why NHSE has such contempt for a profession that has significant achievments and has demonstrated that it is part of a solution to a colossal problem facing the NHS. Perhaps, on behalf of it's members the RPS could commission such a report?

    I have long thought about what we could do if given the opportunity. We are getting hints and training that such an opportunity may be presenting. Services will not be ring fenced for community pharmacy but recent developments demonstrate they won't be ring fenced for GP pharmacists either. However if these opportunities are not exploited we have only ourselves to blame and, if we were to get a new CPO, which we could fantasize as being "you or me", just what would Simon Stevens let us do that he isn't allowing the current incumbent to do?

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