“I laugh every time I talk about this,” says Nikki Kanani about training for her forthcoming athletic debut at the London Marathon in April 2020. “I felt that I needed more to do.”
Perhaps that was the case a few months ago, but Kanani, the medical director for primary care at NHS England may be regretting signing up for it now.
It has been a trying few months for Kanani, with the release of a draft specification for primary care networks creating controversy, owing to the amount of work it entails. Concerns are also coming to the fore about the profitability of the new community pharmacy contract for individual pharmacies.
Despite this, Kanani is a persuasive and positive presence, and engenders much respect for her down-to-earth approach to her job, which she has held for around 18 months. Before that, she was chief clinical officer of NHS Bexley Clinical Commissioning Group and still practises as a GP in south east London.
She is also no stranger to community pharmacy, as The Pharmaceutical Journal discovered when it met her at the NHS England headquarters in south east London.
The system wants to join up and we need to allow that to happen and relationships to build
What has been the most surprising thing you’ve discovered about pharmacy during your time at NHS England?
I quite literally grew up in a community pharmacy, as my family were community pharmacists. We would spend most days in there and I was in the basket on the till when I was a baby. That’s given me my love of community pharmacy — watching my mum and dad have conversations with their patients over the decades was really powerful.
But things have been shifting over the past 18 months. What’s amazed me is that we published the NHS long-term plan in January 2019 and followed that up very quickly with the GP contract, and the community pharmacy contractual framework. And community pharmacy has taken that and said: “We’ll give it a go”. I’ve had community pharmacists and local pharmaceutical committees saying: “We want to be part of this, what’s our role in it?”
Across the country, primary care network clinical directors have said: “We’ve had pharmacists get in touch with us and say: ‘Well, what’s our role? Can we get involved?’” That’s great for me. The system wants to join up and we need to allow that to happen and allow relationships to build.
One of the big developments while you have been in post has been the release of the community pharmacist consultation service. How is that going?
Patients think it’s silly that they haven’t been able to do this more easily in the past. To date, more than 114,000 referrals have come through the scheme; half of those were for urgent supply of medication and half were for minor illness and advice — that’s phenomenal and has a huge impact on the system more widely.
The referral rate works out to about one per week per pharmacy— so it’s not massive a number.
Pharmacy is geared up and is excited about the service, but, in practice, the referral rate has ended up being a little bit less than they expected. However, it’s early days and part of trying out a way of working is seeing if it’s beneficial for the patient, for the professionals and for the system — I think it is. Once you’ve put that time and energy in you ought to be able to see more patients.
We’re piloting referrals from GP practices in four areas. In April 2020, we can start to roll that out a bit further. As a GP, I know there’s a percentage of the people I see who would be better off seeing our clinical pharmacist or a community pharmacist. They’ll get the best advice first, be able to try a set of things before they come and see us and, that’s the idea really, to make sure that the right people see the right person first time.
We’ve been getting some reports of shortages, which include that primary care networks are struggling to find the right pharmacists to employ. Have you heard about this?
Yes, in some areas, particularly in the south west of England, we’ve found that that’s been an issue. And I think it does vary around the country, so some people will say that they’re fully recruited as a primary care network (PCN), while some areas are struggling for one particular group or another. For some areas, they have had to recruit someone who is probably a little less experienced, and that wasn’t necessarily the PCN’s intention, but they’ll be able to do the training and get them on track and equipped to do the things they want to do as a PCN over time.
If primary care networks employ an awful lot of pharmacists, this may cause workforce problems elsewhere — for example in hospitals or community pharmacy. Are you looking at that?
There’s no point in us robbing one part of the system to support another
We do not want to create pressure elsewhere. We’re one system and winning the recruitment argument in primary care doesn’t solve things for secondary care, or anywhere else.
The workforce is absolutely vital to us doing anything in the NHS, especially over the next five years. We published the ‘Interim NHS people plan’ — but we plan to publish the full people plan by March 2020. That will have a strong narrative of how we not only build the numbers that we need, but how we make sure that all different parts of the system are supported. There’s no point in us robbing one part of the system to support another.
The Pharmaceutical Journal published figures that show that around four in ten severely frail patients haven’t had a medication review in the past year. Surely that should be kept to a minimum?
General practice is pretty awesome at looking after patients, we know that from national comparatives. But we do need to level out services and there are some cohorts of our population that really do struggle to get care for lots of different reasons.
What’s important for me is that we get staff into our networks, and then we think about the groups that need our support. We’re in the middle of the next phase of GP contract negotiations and one of the things that we’ve talked about is how we have more comprehensive structure around medication reviews. For example, for our frail and elderly, we make sure a) we identify them; b) we understand what medicines they are on and if it’s the right medicine; and then, c) we make sure they’re using it properly. And that not only looks after the patient better but reduces wastage as well.
How many patients are you expecting to get a structured medication review? It’s not quite clear in the draft specifications.
It’s purposefully not specified, because it will vary network to network. What we put into the specifications is what best practice would look like. We have a system that’s struggling, so we’re not going to be able to do all of that. It’s really easy for us to look at what a good system looks like nationally, but how to deliver that in a struggling system has to be carefully thought out.
Like how to deliver it in the south west of England, for example?
People need to feel excited about going to work, they need to feel valued for the job they do
Exactly. I know it is difficult when we put out specifications that feel complicated. That doesn’t mean we will use them for performance management and that’s what I want to ensure we stay away from. There is no point in me managing a 23,000 network at the other end of the country that for ‘X’ reason has done ‘X’ number of structured medication reviews (SMRs) — that’s well outside of my gift or wish. What I want is for networks to work collectively together and say: “This is the cohort we want to offer to, this is our clinical pharmacists’ capacity. That’s the number of SMRs we’re offering.”
Clinical pharmacists do not want to spend all their time doing SMRs. We’ve seen a change in general practice in the way that our workforce wants to work, and we have seen that in pharmacy as well. I’m so proud of the way my dad orders and stocks medicines, but that’s not what preregistration trainees want anymore, by and large. They want to work in a pharmacy, but they’re not excited about the buying and selling as much as they are about the clinical aspects of the service. Building this into this model of care is as important as optimising the use of clinical pharmacy within the system. People need to feel excited about going to work, they need to feel valued for the job they do.
You are leading on the review into whether high-dose statins should be available on general sale in pharmacies. Do you think there is evidence supporting that?
This review is about the much bigger question of how we support our population to stay well. People want our communities to be more empowered to look after themselves and it’s kind of past the point where we say: “You must take it and that’s it.” But I think there’s also a wider agenda around overprescribing and overdiagnosis, and we need to be clear about what we want to do, before we decide how to do it.
We’re at the exploratory stage, so let’s understand what the evidence base is first, before we make any kind of commitments to do anything else. It’s not that our community pharmacist colleagues aren’t able to sell and advise on them, if that’s the right thing to do, but let’s make sure we get the questions right in the first place.
A Royal Pharmaceutical Society survey showed that around 80% of pharmacists were at risk of burnout, which is an extraordinary figure. GPs were at a similar level once, which led to a scheme being brought in to support them. Why isn’t there similar support for pharmacists in the NHS?
I did see that survey from colleagues at the Royal Pharmaceutical Society. It’s not tolerable in any part of our profession for anyone to feel that way. Some of that is about getting the basics right at the beginning. One of the things we are looking at in the people plan is a core offer for the whole NHS: how to make sure that our staff feel valued and that they don’t end up feeling exhausted. The job is always going to be difficult, but it shouldn’t mean that it ends up in burnout and stress. So, expect more in the people plan.