Sustainability and transformation plans: is pharmacy’s voice being heard?

Sustainability and transformation plans (STPs) are the blueprints for the future of the NHS, setting out how 44 areas across England — identified as geographical STP ‘footprints’ — plan to get the best health outcomes for their populations from increasingly stretched financial resources.

The plans — which support the delivery of the ‘Five year forward view’, published in October 2014^[1]
— were announced in NHS planning guidance in December 2015  to ensure health and care services are built around the needs of local populations^[2]
.

Many of the solutions to the problems the NHS faces have a link to pharmacy — from the need for greater efficiency in hospitals through to keeping older people at home or in residential care rather than in hospital.

STPs are being drawn up by groups of local NHS organisations and local authorities, with a lead who is generally the chief executive of a NHS trust or an accountable officer from a clinical commissioning group.  Pharmacists should be able to bring their knowledge and skills to the table to help develop deliverable solutions which have the buy-in of healthcare professionals.

But these groups have widely criticised the low level of engagement by pharmacists.

Pharmacist engagement

Robbie Turner, director for England at the Royal Pharmaceutical Society, the professional leadership body for pharmacists in Great Britain, argues that engagement with pharmacists has been “variable and, in the main, disappointing”.

“What we have heard from our members is that STPs have been drawn up by the same people who have been engaged in system design for the last ten years,” he says.

Not involving pharmacy in the creation and implementation of STPs has risks that may pose missed opportunities for transformational change, Turner adds. NHS system leaders, who create the plans, need to recognise the role of pharmacists, not just in terms of delivery of services to patients, but in the design and decision-making around how the NHS will meet the challenges of the future, he says.

If you are not at the right table, you don’t know what is going on

Rahul Singal, pharmacy and medicines lead for the South East London STP, points out that much of what is happening in STPs is at high level and therefore hard to translate to the working lives of pharmacists, both in community and in hospitals. Eventually, of course, these changes will have profound effects on many people working in healthcare, but Singal argues that it may take something that directly affects pharmacists to bring it home to them.

David Campbell, chief pharmacist at Northumbria Healthcare Foundation Trust, warns against unrealistic expectations of how much pharmacy will be name-checked in high-level STP documents. There is a need to interpret where pharmacy fits into the ‘big picture’, he says.

Campbell’s area is developing a more integrated pharmacy service that spreads from hospital through to community hubs from which pharmacists can provide services to people identified through a risk stratification service. The benefits of this more integrated service include patient discharge not being delayed by minor problems with medications, because the community-based team can deal with them.

Direct mention of pharmacy or pharmacists in many of the 44 STPs tends to be limited. Kent and Medway’s STP has just two, for example
^[3]
.  One on developing workforce — specifically in community and primary pharmacy — and one on the role of community pharmacists in the future model of care.

Arguably, local pharmacy networks (LPNs), which provide clinical input into NHS England’s local area teams and support implementation of policy, could play a greater role.

Martin Stephens, chair of the Wessex LPN, says they have not generally been “front and centre”, although there are examples where this is not the case. For example, he says, Hampshire and Isle of Wight Local Pharmaceutical Committee (LPC) set up a meeting to look at community pharmacy’s role in the local STP and key leaders from the STP joined the discussions.

The ‘top table’ of most STPs will involve chief executives from the participating organisations and generally there are few pharmacists. Further down in the structure of STPs, where there are usually a number of boards looking at particular themes or programmes of work, pharmacists may be more evident. In South East London, for example, several pharmacists sit on its STP project boards. As a result, personal relationships between pharmacy leaders and those at the top of STPs or with the ability to influence them are important.

Liz Stafford, communications and engagement lead for Community Pharmacy Lancashire, which represents community pharmacy contractors in Lancashire, says: “We have nurtured some key relationships with directors of public health and GPs.”

The same is true in Northumbria, where existing relationships and local vanguard schemes have helped advance pharmacy’s case within the STP.

Hospital/community split

Many STPs are splitting their activities into different work streams: pharmacy often sits across several while community and hospital pharmacy may be separated. Hospital pharmacy can be seen as a clinical support service — which rather ignores the autonomy of pharmacists — or as part of a procurement stream. Some areas have a separate medicines stream that often recognises pharmacy’s value in providing clinical care and improving outcomes for patients.

There is a bit of a hospital/primary care split at the moment, which is probably unhelpful

“If you are not at the right table, you don’t know what is going on,” says Roger Fernandes, chief pharmacist at King’s College Hospital Foundation Trust.

While Fernandes’ STP footprint area in South East London has pharmacists actively involved, he has heard from colleagues elsewhere that pharmacy is struggling to have its voice heard.

Singal agrees that there can be division between how hospital pharmacy is treated compared with community and primary care pharmacy. He is currently working within the provider productivity work stream looking at making the efficiencies in hospitals that were outlined in the Carter review
^[4]
. But community pharmacy and primary care come under other areas, he says, suggesting that perhaps a more joined-up approach is required.

“There is a bit of a hospital/primary care split at the moment, which is probably unhelpful,” he adds.

Fernandes points out that when the South East England STP looked at out-of-hours medicines optimisation, this brought hospital pharmacists more into contact with their community-based colleagues.

Hospital-based pharmacy has an obvious structure, allowing a chief pharmacist or deputy chief pharmacist to be invited onto STP project boards. In South East London, there was already close working between the chief pharmacists of trusts in the area. “We have a good history of collaboration and this was our starting point,” Fernandes says.

But no such structure exists for community pharmacy, except through local pharmacy committees (LPCs) as broad representative bodies with powers to ‘force’ their local members to do anything.

Where are the opportunities?

There are a number of common themes in all 44 STP documents that could directly impact pharmacy:

• Hospitals will be under pressure to reduce costs through streamlined processes and greater joint working across hospitals. In pharmacy terms, this could lead to more centralised units for some specialist services, such as aseptic units. These changes are very much in line with those proposed as a result of the Carter review but the focus of STPs on reducing costs across wider areas will give them greater impetus.
• Some STPs are looking to scale up initiatives pioneered in vanguards, such as greater involvement of pharmacists in care homes to prevent admissions. In some areas, there has been movement towards accountable care organisations, where a single NHS organisation takes on a budget and provides services for all parts of the patient’s pathway. Pharmacy could have a role to play in this.
• STP teams are keen to reduce the number of people taking up expensive hospital beds, and plan to do this through early interventions in the community to keep people out of hospital and providing care at home for less serious cases. Facilitating supported early discharge could be another area where pharmacy input is vital.
• Relieving the pressure on other healthcare professionals by diverting appropriate patients to services delivered by pharmacy staff. This could impact on community pharmacists – who might take on additional services that keep people out of GP services – but there could also be opportunities to have more pharmacists working in A&E departments, as the Royal Pharmaceutical Society has proposed.

Pharmacists — especially those seeking new opportunities because they are facing cuts to their income — would welcome many of these changes and recognise they could both develop the pharmacy ‘offering’ and start to make more of a difference to patients’ health and well-being.

There is an opportunity to explore innovative ways in which community pharmacies can engage

While some of these changes will take three to five years to bring about, some STPs have pledged to start rolling out existing projects across a wider area. In Lancashire, for example, £250,000 has been pledged to roll out ‘Healthy Living Pharmacies’ to a level two standard of the health living pharmacies framework
^[5]
. This funding came through the local branch of Health Education England, the executive non-departmental public body of the Department of Health.

In the same STP area in Lancashire, Pharmacy Plus clinics offering minor illness treatment through pharmacies are also set to spread across the patch: it started in a vanguard area.

In South East London, one of the earliest effects of the STP for pharmacists will be the introduction of a rotation for newly qualified pharmacists. From September 2017, they will be offered the chance to move between hospitals, community pharmacies and in GP surgeries. Other changes could take longer. Some services, not yet specified, may be provided across the hospitals in the STP rather than provided at each individual one , which could demand more flexible working from pharmacists, and shared ‘back office’ services.

Often these projects are underpinned by better IT, allowing pharmacies access to electronic patient records, and are roll-outs of existing services that have been limited in geographical scope, rather than entirely new services. However, despite the financial state of the NHS, money is being found.

“There is an opportunity to explore innovative ways in which community pharmacies can engage so that if new tenders go out, prime providers can subcontract to them to deliver a raft of new services,” Stafford says.

What are the challenges?

Once pharmacy is involved in STPs, it can be a challenge for those at the centre to find the time to be fully involved.

Singal says the South East London STP has “a dedicated resource” around pharmacy.

“We are recruiting three other project managers,” he explains. “We are putting resources in to do it properly. And we are well embedded in the governance process. We are not on the sidelines.”

However, LPCs – which are already small – may face challenges in attending all STP meetings and taking on some of the work in developing proposals. Singal cautions that active involvement in STPs requires “time and headspace” and is difficult to do as well as the day job. He also warns that it may be necessary for pharmacists to take on some additional work without pay initially and wait for commissioning to come through.

The people behind STPs also need to take advantage of what has already been tried successfully. The 44 STP areas need to learn from each other, too, so they don’t become bigger silos. There are example of changes involving pharmacists across all STP areas that could be adopted and make a difference quickly.

Turner also points to where pharmacists have been involved in care home vanguards, carrying out work such as medication reviews. This type of intervention resulted in reduced costs to the NHS as well as reduced health risks for care home residents. These approaches could be adopted quickly elsewhere and bring almost immediate benefits.

However, he adds: “STPs risk the same fate that other organisational changes have had in the NHS, which is trying to reinvent things and not learning from some of the examples and evaluations because pharmacy has not been brought into the decision making at an early stage.”

“But,” he concludes, “it is not too late.”