General Comments

The EPB supports the Department of Health’s aim to strengthen public health provision, via a new National Public Health Service. Pharmacists are involved in the provision of many differing aspects of public health across the country on a daily basis and have much to offer such a service.

Needs assessment in the global sense is important to ensure that appropriate services are developed to meet need. The EPB believes that pharmacy led public health services should be a major consideration for the new National Public Health organisation for England. Wales has benefited from having a team of pharmacists in Public Health Wales (formerly the National Public Health Service for Wales) dedicated to that discipline.

The EPB also believes it is essential to ensure that funding for public health is hypothecated and that funding is commensurate with services that will deliver a high standard of care and bring real benefits to patients and the public. We support the ring-fencing of funding for public health but there is a need to ensure the funding is ring-fenced at both national and local levels.

To do this, several issues need to be addressed:

i) A clear definition of what types of services are considered to be within the remit of public health. Many community pharmacies in England already provide healthchecks and screening for a range of conditions e.g. cardiovascular checks and chlamydia screening and provide services that protect the health of the population as well as the individual e.g.  vaccinations and immunisations. Additionally public health services such as smoking cessation and weight management are more established though not universally available and access may therefore be inequitable. Having pharmacy-led services in the new national public health body would help address issues such as equity of access and evidence of outcomes and quality in relation to pharmacy delivered public health services. Community pharmacy-based stop smoking services run by trained pharmacy staff are cost effective. Abstinence rates achieved by one-to-one smoking cessation services provided by community pharmacists and primary care nurses are similar and although quit rates are lower for one-to-one advice than group interventions with specialist behavioural support, pharmacy is able to cater for large numbers at a time and in locations that are acceptable to patients. [1]  In Scotland in 2009 56% of quit attempts were made through community pharmacy delivered services, although in some areas this was as high as 83%. [2].

ii) The patient pathways defined by some public health initiatives, such as screening services, will cross from public health to mainstream NHS treatment and ongoing care. A clear understanding of budget responsibilities, roles, remits and expectations will need to be developed before such a system will be able to operate effectively. 

iii) GP consortia and local authorities (LAs) will need to co-ordinate healthcare planning to ensure that the scope and scale of services are suitable for the numbers of patients transferring from public health screening to mainstream NHS treatment to provide a seamless care pathway for individual patients.

iv)  The prevention of ill health and delivering health improvement must be embedded into the NHS services and whilst the EPB understands the rationale of moving responsibility for public health to local authorities, it is concerned that much of the current integration with mainstream NHS care will be lost.   An example of this is a Chlamydia service which currently provides testing, treatment and tracing of partners. The testing element of this service could be viewed as public health and would fall under the remit of LAs, whereas the treatment element is likely to fall under the remit of the NHS. This would lead to a fragmentation of a currently integrated service potentially leading to poorer outcomes for patients.

Pharmacy is the only healthcare provider that engages with patients whilst they consider themselves well. In many instances, pharmacists are sited in towns and communities with high levels of deprivation, higher than average morbidity and low levels of health literacy.  Pharmacists are well positioned to identify and approach people from target groups e.g. persons from ethnic communities, the elderly and the vulnerable, asylum seekers and the homeless, and could offer services that more traditional NHS services may not offer, and in premises which are more convenient, thereby improving access and uptake.  A number of community pharmacies provide bespoke services for these vulnerable people and we would like that particular role to be strengthened and supported as the new NHS structures develop.

The current pharmacy contract ensures that the public receives up to six health promotion campaigns each year as agreed with the Primary Care Trust (PCT). The EPB would wish to build on this with the new public health service to deliver efficient and effective campaigns.  We would like further clarity on how the new NHS structures will maintain and enhance this service in the future. Pharmacists have played a role in reducing health inequalities, particularly in the areas of smoking cessation and sexual health. The role of pharmacists in public health should be recognised and developed further in order to maximise benefit and reduce the overall burden of smoking related illness and sexually transmitted infections on the NHS.

We would support the further development of the Healthy Living Pharmacy model, currently being piloted by Portsmouth PCT. This could form the basis of the delivery of a quality based public health service.

Pharmacy has a role in not only preventing ill health but also in maintaining the health of those patients with Long Term Conditions (LTCs). Pharmacists provide advice on the management of LTCs and self care and advice and support on the safe and effective use of medicines taken by patients. At the strategic level pharmacists currently lead in areas of horizon scanning, financial planning and surveillance of medicines use. The importance of these functions to current PCTs and SHAs is recognised and must be factored into any new NHS infrastructure. The EPB has some reservations around GPs ability to fully deliver this type of function in any new commissioning arrangements without pharmacist input at the appropriate level.

The community pharmacy network is highly accessible to patients and the public – many of whom will not necessarily access other parts of the NHS. 99% of the population being able to access a pharmacy within 20 minutes by car and 96% by walking or using public transport [3].  This network can be used, not only to harness public and patient views, but also to provide information such as public health messages. Community pharmacy is the window to the NHS on every high street and should be promoted as the first port of call for health promotion and prevention of ill health, treatment and advice on minor ailments, management of LTCs and support and advice on medicines. Community pharmacy is highly accessible for patients of the NHS and those seeking to maintain good health. As well as being trusted by many patients, community pharmacies make an obvious venue for delivery of NHS primary care services. The informality and accessibility of pharmacy encourages patients to feel comfortable in raising difficult or embarrassing problems that they may not want to see the GP about, such as sexual health advice. It also means that when patients present themselves with one problem, other aspects of their health can be assessed and responded to [4].

 

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Specific questions   

1. Should local HealthWatch have a formal role in seeking patients’ views on whether local providers and commissioners of NHS services are taking account of the NHS Constitution?

We believe they should have a role.

2. Should local HealthWatch take on the wider role outlined in paragraph 17, with responsibility for complaints advocacy and supporting individuals to exercise choice and control?

The EPB supports a wider role for local HealthWatch (LHW). It is important for LHW to understand the range of experience and expertise available from other healthcare providers in order for it to undertake this enhanced role.

The EPB believes that it is important for patients and the public to have a source of impartial, balanced advice on the range of care providers available within any specified consortium. We believe this role needs to be informed by the outcomes of any complaints received or concerns raised over individual providers.

3. What needs to be done to enable local authorities to be the most effective commissioners of local HealthWatch?

We believe that LHW should report back to the LA via a statutory framework such as  the publication of  an annual report. Professionals and the public should have the ability to comment on drafts of this report.

There should also be standard templates for service provision and a named person at the LA responsible for the tendering and commissioning process.

There needs to be health expertise in LAs to ensure effective commissioning of local NHS services.

The learning from successful LINks should be collated and disseminated to LAs in order to inform future commissioning of local HealthWatch

4. What more, if anything, could and should the Department do to free up the use of flexibilities to support integrated working?

Truly integrated working can only be achieved by changing the present commissioning system that sets one provider against another. It is clear that, ultimately, there is a need for a commissioning process, but commissioners should look to commissioning a service that utilises the best-placed healthcare practitioner to deliver each aspect of a patient pathway:

GPs for diagnosis, hospitals for any referral to secondary care, and other healthcare providers, such as pharmacy, for ongoing care. The EPB believes substantial cost savings could be made by utilising the provider most suited to the provision of each individual stage within a patient pathway. Substantial cost savings are also possible if the Department considers undertaking a minor realignment of roles. Chair of the Royal College of General Practitioners, Steve Field, confirmed to the Health Select Committee that approximately 51 million GP visits per year could be managed by community pharmacy. Research indicates that a pharmacy-led minor ailments service could save approximately £14.25 per consultation – an approximate saving of £800m per year. [1]

Historically, it has been difficult to change the behaviours of those making decisions in the NHS. For this model to work in a relatively short period of time, it will be important to change the current system of financial incentives, the Quality and Outcomes Framework (QOF) system, to include a payment for utilising the full range of service providers available within any specific patient pathway. Consortium commissioning must also be judged against the most cost-effective use of public money for securing services.

The EPB recommends that commissioners look to using consortia comprising local healthcare practitioners, required to address every stage within a specific patient pathway.

The EPB has been working with the Royal College of GPs to produce a report on how both professions can deliver a more co-ordinated healthcare service. It examines how professionals can work together to provide a truly integrated care pathway for patients, save public money and deliver better patient outcomes. This will be published in the next few months and both organisations would be pleased to engage with the Department of Health once this work is complete.

The EPB believes that, in promoting an ‘any willing provider’ model, the Department must introduce an effective process of informing and signposting patients to enable them to make a decision on the correct and most suitable form of care. The EPB would like to see the NHS Commissioning Board monitor the number of services provided by each profession and individual provider, as one indicator of the quality of care a provider is able to deliver to patients.

Effective communication between healthcare providers is essential for effective flexible co-working. There is the potential for the same members of the public to be offered screening by a multitude of healthcare providers purely because there is no current way of determining who has already been offered screening. The only effective method of facilitating the levels of communication required, are for all providers to have access to patient records. 

5. What further freedoms and flexibilities would support and incentivise integrated working?

Care pathways need to be developed that include all the relevant professionals and providers. There need to be systems in place that compel providers to work together.

Changes to the national contracts for professions should be considered to incentivise and promote new methods of collaborative working.

Locally, integrated working would be incentivised by the embedding of collaboration and common goals into the locally agreed care pathways to enable confident investment in integration and service delivery by providers

6. Should the responsibility for local authorities to support joint working on health and wellbeing be underpinned by statutory powers?

Yes, we agree that there should be minimal statutory powers in place to reduce duplication of effort and to assist consistency. Additionally, the same measures need to refer to GP consortia. The most important area where joint working must be achieved is on delivery of JSNA. Currently, the EPB can see no evidence that consortia need to commission services identified in a JSNA.

The HWB is the only body that will be able to assess whether delivery of services across all commissioning organisations, meets the needs of the community which they serve.

7. Do you agree with the proposal to create a statutory health and wellbeing board or should it be left to local authorities to decide how to take forward joint working arrangements?

One of the stated aims of the white paper is to take politics out of healthcare. The EPB feels this cannot be achieved without some form of consistency of structure and remit being described for local authorities to follow. Further, the EPB feels it is desirable if all commissioners and providers have a forum at which they can co-ordinate activity, scrutinise delivery and hold commissioners and providers to account. There is a real need for one of the bodies to have a more strategic view of healthcare, which, under these arrangements, should be LAs. In light of this, a statutory HWB would provide such a forum, allowing all relevant stakeholders to gain an understanding of healthcare at a more strategic level and understand how the work of all stakeholders fits in to provide a holistic solution to health and social care.   We believe that the more local councillors talk with health professionals and understand the issues, the better this will be for local decision making.

The EPB feels HWB meetings should be held in public and believes that all the statutory representative bodies should have a place on these boards. We believe that the HWB should be responsible for the creation of the JSNA in addition to holding healthcare commissioners and providers to account for any shortfall in delivery.  There must also be a process of escalation if agreement on unresolved issues such as delivery against the JSNA cannot be agreed by members of the HWB

8. Do you agree that the proposed health and wellbeing board should have the main functions described in paragraph 30?

Yes, we would agree with these functions. In addition, we feel the HWB should have robust processes that enable it to hold to account any of the stakeholder organisations, commissioners or providers involved in local healthcare. The HWB needs to have powers to investigate poor performance of service providers and there needs to be consequences if providers who consistently underperform and commissioners who fail to take action.

9. Is there a need for further support to the proposed health and wellbeing boards in carrying out aspects of these functions, for example information on best practice in undertaking joint strategic needs assessments?

The HWB will initially have little understanding of the capacity and capability of all providers, how they are funded etc and they may require some support in understanding both this and the new NHS structure.

10. If a health and wellbeing board was created, how do you see the proposals fitting with the current duty to cooperate through children’s trusts?

We have no comment to make in relation to this question

11. How should local health and wellbeing boards operate where there are arrangements in place to work across local authority areas, for example building on the work done in Greater Manchester or in London with the link to the Mayor?

We believe that where there are arrangements across LA areas, providers will be asked to deliver differing types of service. It is likely that LAs will work together to provide similar standards of care where boundaries are not co-terminus. There may be a role for over-arching bodies, such as the offices of mayors, or higher tier LAs, but it is likely LAs will find their own solutions to this issue. Local variation is an inherent part of a healthcare environment that encourages and facilitates localised solutions. 

We do not expect this being an area of concern as long as all of the constituent boards work collaboratively in agreement. In extreme cases, where healthcare is affected by a disjointed approach by stakeholder organisations, we would expect the NHS Commissioning Board, HealthWatch and possibly the Local Government Association to play an important role in either finding a resolution or minimising contrasts in care.

12. Do you agree with our proposals for membership requirements set out in paragraph 38 - 41?

We agree with the Department’s proposals but would also add a place for every other healthcare professional. It is likely that at some point the HWB will discuss issues around pharmacy-led services. It will be beneficial for a pharmacist to be present to be able at least, inform the debate and ensure the right outcomes are reached. This should also be the case for any other profession involved in healthcare provision – as the Optical Confederation says in its submission: “Providing the principles of fairness and equal and transparent treatment are complied with, we would argue that it is absolutely essential that providers are involved in these discussions.” 

Medicines are the most common intervention in the provision of healthcare. Pharmacists are the experts in medicines and therefore, should rightly have a place at the table where treatment with medicines is being discussed.

13. What support might commissioners and local authorities need to empower them to resolve disputes locally, when they arise?

There should be an official referral network to help solve local disputes. It is not currently clear what powers the LAs and GP consortia have to enable them to solve such disputes.

14. Do you agree that the scrutiny and referral function of the current health OSC should be subsumed within the health and wellbeing board (if boards are created)?

Yes. In the interests of transparency, scrutiny would need to take place in conjunction with agreed patient outcomes, using standardised metrics, which could be used as a benchmark by every HWB, as those being scrutinised are likely to be members of the HWB. The EPB expects bodies with a national function such as the NHS Commissioning Board and HealthWatch, to play a role in comparing local outcomes against publicly available information on all healthcare providers.

Appropriate governance procedures will need to be developed to prevent a conflict between the planning and oversight role of HWB boards.

15. How best can we ensure that arrangements for scrutiny and referral maximise local resolution of disputes and minimise escalation to the national level?

Local organisations will require the assistance and guidance of national organisations for support. Professional bodies should be able to provide model standards of care, such as those the RPS is proposing to develop for the pharmacy profession, available to commissioners upon request. Additionally, standardised contracts for service providers should be available to commissioners, for reference and possible adoption as part of a good practice measure.

A process of performance management throughout a service provider’s contract will reduce the element of dispute and inform subsequent commissioning decisions.

16. What arrangements should the local authority put in place to ensure that there is effective scrutiny of the health and wellbeing board’s functions? To what extent should this be prescribed?

The EPB anticipates that the HWB will be required to report to the full Council, which in turn reports to residents.

17. What action needs to be taken to ensure that no-one is disadvantaged by the proposals, and how do you think they can promote equality of opportunity and outcome for all patients, the public and, where appropriate, staff?

Patients and the public must be able to access clear, accurate and timely information on all healthcare providers in their area. They must be offered unbiased advice on what is best for them and their specific condition.  Every action taken by a healthcare provider must be framed around the patient.

For providers, the commissioning process needs to take into account that there will be a number of independent providers whose capability to respond to formal tender processes will vary. There should be sufficient support for any new entrants who may not have the experience or resources to go through a tendering process but may be able to achieve the highest standards of care.

18. Do you have any other comments on this document?

The consultation document introduces the concept of a National Public Health Service. It is unclear where this organisation will sit and how it will interact with the Department of Health and other organisations within the NHS structure. We would encourage the government to ensure that this organisation is well serviced by all those involved in health and social care and that this would include pharmacy.

We have a number of specific concerns about the proposals in this document:

• It is unclear in the document as to where market entry for pharmacies will sit. The Joint Strategic Needs Assessment is to be led by HWBs and sit within the LAs. We are assuming that the Pharmaceutical Needs Assessment (PNA), which is to be used as a ‘control of entry’ tool in the future, will sit alongside this.  However, GP consortia are budget holders and it is likely they will determine if a pharmacy should open or not – there needs to be further clarification around these processes particularly if GPs involved in these decisions have a commercial interest in whether a pharmacy is allowed to commence operating within a defined area.
• Clarity is required on how LAs and GP consortia work together, especially around the delivery of public health services where there are likely to be referrals into the healthcare system. On reading this consultation there does not appear to be any requirement of GP consortia to commission services identified in the JSNA. And there appears to be little ability for LAs to ensure that the JSNA is delivered
• The consultation document does not mention the formal professional representative bodies at all e.g. local pharmaceutical committees and local optical committees. There needs to be clarity on the future of these organisations and how they fit into the local and national healthcare infrastructure.
• The geographical boundaries of GP consortia will not necessarily reflect those of the LA. There is a potential for providers to be asked to provide the same service to differing standards within the community a particular consortium serves. It is highly likely patients and the public will be required to provide their postcodes before receiving care, to ensure that the service provided meets the standards expected by the relevant HWB.
• We are concerned about the ability of HWBs to scrutinise the activities of those providers who are also members of the HWB.
• We are keen to understand what steps are in place to ensure the continuity of local enhanced services during the transition period to ensure the public and patients are not disadvantaged. We would like to engage with the relevant stakeholders for discussions on how to manage the transition and maintain continuity of service provision. For example patients in the Surrey PCT area are no longer able to access stop smoking services via their local community pharmacies.

For further information or any queries you may have on our consultation response please contact Heidi Wright at  or 0207 572 2602.

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References

1. Healthy Living Pharmacy Project, a literature review. December 2009
2. NHS Smoking Cessation service Statistics (Scotland) 2009
3. The Bow Group target paper. Delivering Enhanced Pharmacy Services in a modern NHS: Improving Outcomes in Public Health and Long-Term Conditions
4. CBI report Best of Health, Improving Lives through Smarter Care. Feb 2010