primary care in the twenty-first century

Primary Care in the Twenty-first CenturyRealising the promise of rapid service access and well-coordinated person centred health and social care at every stage of life

Summary• TheNHSremainsoneoftheworld’sbetterhealthcaresystems.ButtheproportionoftheUK’sGDPallocated

tohealthandsocialcareisonlyaboutthreequartersofthatnowspentbyleadingEuropeannations.TomeetchangingneedshealthandsocialcareprovidersinEnglandmustimprovetheircapacitytoofferconvenientaccesstopreventiveand‘commonneed’diagnosticandtreatmentservicestopeopleofallages,andalsotoprovidewell-coordinatedsocialandhealthcaretoindividualsathighriskofsufferingavoidableepisodesofseriousillnessandneedlesslylosingtheirindependence.

• Ifpersonalandpublichealthistoberaisedtothehighestpossiblelevelimprovingprimaryhealthandhealthrelatedsocialcare–whichtogetherrepresentlittlemorethanafifthofcombinedNHSandlocalauthoritysocialserviceoutlays–isvital.Healthcarewillinfuturemovemoretowardsprofessionallyfacilitatedpreventionandprimarycaresupportedself-careinthecommunity,backedbytherelativelyinfrequentuseofhighlyspecialisedservicessuppliedinhospitals.

• TheuniqueattributesofBritishgeneralmedicalpracticewillallowittoserveasacentralplankforcontinuingservicedevelopment.TheformationoflocalHealthFederationsandrelatedprimarycarefocusedorganisationscouldinfuturelenditselftoholdingsinglebudgetsforhealthandrelatedsocialcarealongthelinesproposedbyadvocatesofthePrimaryCareHomeapproachtoserviceimprovement.Thiswouldoffersignificantgainsforserviceusers.Wherevercosteffective,servicesoughttobe‘made’bylocalcareproviders.Wherenecessarytheyshouldbepurchasedfromothersources.

• ThereisalargebodyofevidenceindicatingthatCommunityPharmacycanplayanextendedpartindeliveringaccessiblehealthcare,alongsideroleslikereducingprescriptionerrorsandfacilitatingbettermedicinesuse.IncreasingthenumberofclinicalpharmacistsworkinginGPpracticesisavaluablestep.Butitcannotsubstituteforaclearvisionforthefutureofcommunitypharmaciesas‘firstcontact’healthcareproviders.

• If communitypharmacists successfully extend their clinical care roles thiswould freegeneralpracticeandlinked community capacity to work towards reducing inappropriate hospital admissions and unduly longinpatient stays.Withoutwell planned,pro-active, interventionspharmacy skillswill beunder-usedand theestablishedcommunitypharmacynetworklost.YetifeachcommunitypharmacyinEnglandwereabletotakeonjust10percentoftheaveragegeneralpractice’sexistingworkloadoverthenextfiveyears,thiswillreleaseapproaching5,000GPsandsimilarvolumesofpracticestaffforadditionalserviceprovision.

• ResponsibilityforachievingmoreeffectiveprimarycareworkingarrangementsliesmainlywithGPs,nurses,socialworkersandpharmacists themselves,becauseonly theyare inaposition toadequatelyunderstandthetaskswithwhichtheyareengagedandthedetailedneedsofthepeopletheyserve.However,individualprofessionals alone cannot transform theNHS. Excellent national leadership and appropriate funding andgovernancesystemsarealsovitalfornation-widesuccess.

• Nineoutof10people inEnglandcurrently livewithina20minutewalkof acommunitypharmacy.Someplannersmaywishtoseesavingsmadeviaconcentratingdispensinginwarehouse-likefacilitiesandincreasingthe useofmedicines homedelivery services.Yet at a system-wide level a potentiallymoredesirablewayforwardcouldbetoextendpharmacistprescribingand improvesharedhealthrecordsystems.Thiswouldcombineconvenient localmedicines supplywithmoreaccessible formsof ‘pharmacist first’ care in areasrangingfrommanagingbloodpressuretoprovidingbetterchronicobstructivepulmonarydisease(COPD)andtype2diabetespreventionandcare.

• ThehealthandsocialcaresysteminEnglandhasbeenaffectedbyimbalancesthatarelinkedtothefactthatsocialcareismeanstestedwhileNHScareisfree.Thishascreatedperverseincentivesthatmayinthepasthaveunderminedservicessuchascommunitynursing.Inadequatehighlevelleadershipalsoimpairsservicequality.But ifhealthgainfocusedco-operativeprofessionalenterprisecanbecombinedwithwell-informeddecisionmakingandrobustnationalandlocalresourceallocationstrategiesthateffectivelysupportthedeliveryofwell-coordinatedprimarycare,furtherimprovementsinindividualandpopulationhealthwillbeachieved.

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2 PrimaryCareintheTwenty-firstCentury

IntroductionSophisticated hospital care can be life-saving, or playanimportantpartinpreventingandalleviatingdisabilitiesand restoring normal daily activities. Even after hopesofcurehavefaded,hospitaltreatmentsextendsurvivalandrelieveacutedistress.WhenpeoplerefertoBritain’sNational Health Service as being one of the world’sbesthealthcaresystems it is frequentlybecauseof itscapacitytoofferaccesstohospitalcare–theprovisionof which is conventionally estimated to account foraround two thirds of all UK health service spending –withoutindividualshavingtoworryaboutitsimmediateaffordabilityforthemandtheirfamilies.

The continuing ability of the NHS in England and theotherUKcountriestoprovide‘cuttingedge’acuteandelectivehospital care topeople in exceptionalmedicalneedwillremainessentialifitistogoonbeingtrusted.However, for public health to be raised to the higheststandards possible, and for people living with long-term conditions and establisheddisabilities to be abletomaximisetheirwellbeing,excellenceinthedeliveryof‘hightechnologymedicine’ininstitutionalsettingsaloneisnotenough. Itmustbeaccompaniedby the robustprovisionofprimaryhealthcare(including–asprimarycareisdefinedhere–communitynursingandpharmacy,andalso communitymental health care) togetherwithsocial services that offer high quality support for dailylivingand,whenitisneeded,accesstoresidentialcare.

Total NHS spending on ‘family practitioner services’(including all community medicines costs, and publicspending on general dental and ophthalmic services)today accounts for only a fifth of total health serviceoutlays.Yet theworkofGPs, communitypharmacistsand other primary care professionals is central to thecost effective provision of health care as a whole. Inwell-functioningsystems,primarycareprovidedbynotonlyGPsbutalsohealthprofessionals likenursesandpharmacists provides ‘first contact’ support acrosspopulations that is when it is required to be person-centred,continuous(thatis,isbasedonrelationshipsthatendureovertime)comprehensiveandwell-coordinated–seeBox1.

Primary care services should also be convenient andpleasant to use asmeasured by the standards of thecommunities in which they are provided, and able torespond quickly and reliably at the interface betweenself-care and professionally delivered interventions.Thereisrobustevidencethatagoodrelationshipwithafreelychosenprimarycaredoctor,preferablysustainedover years, is associatedwith better health outcomesthanwouldotherwisebepossible(Starfieldetal,2005).NHSgeneralpracticehasbeendescribedas‘the soul of a community orientated health-preserving system’(Berwick,2008).

Effectiveprimarycarecomplementsand reinforces theimpactsof‘impersonal’publichealthprogrammesaimedat creating protective environments and stimulatingbeneficialbehaviouralchangesacrossentirepopulations.Italsoenablesspecialiseddisease-centredinterventionsto takeplace in timely andoptimally productiveways.Without good primary care, hospitals are inevitablyburdenedbyavoidableorundulylateadmissionsandbyinappropriatelydelayeddischarges.

As Figure 1 outlines, the activities ofGPs, communitypharmacists and allied service providers range fromprimary prevention (disease avoidance via measuresranging from immunisation to smoking cessation) andrespondingtotraumaandacutesymptomsthroughtoprovidingdiagnosesandreferralstospecialists.Primarycare practitioners also provide secondary prevention(earlystagedisease treatment)andsupport forpeoplewith long term conditions, and can be central to latestageillnessandend-of-lifecare.

Theneedsofchildrenandyoungadultsarenormallyverydifferentfromthoseofpeopleintheireightiesandabove.Even within age groups individuals’ requirements varywidely.Yetprimarycareasawholeshouldbeinclusiveandofferasetoffamiliar‘frontdoors’tohealthandalliedcaretoallmembersofthecommunity.

Figure 2 is indicative of the changing nature of healthand social care and the potential for communitypharmacyto–inconstructivepartnershipwithGeneralPractice – play an increased part in meeting modernserviceneeds.Demandforenhancedprimarycarewillcontinuetoexpandasnewhealthtechnologiespresentfreshopportunitiesforpreventionandtreatmentoutsidehospitals and GP’s surgeries, and increased levels ofeducationandaccesstoinformationchangepublicandprofessional understandings of health and illness andgeneratenewserviceexpectations.Twentyfirstcenturyhealth care will almost certainly move further in thedirectionofprofessionallyfacilitatedpreventiveself-careinthecommunity,backedbytherelativelyinfrequentuseofhighlyspecialisedservicesinhospitals.

GeneralMedicalPractitionershavealwaysbeencentralto NHS primary care. For many people their GeneralPractice(and,withinit,theirGP)is,especiallyaftertheyhavehadchildrenorhaveenteredthelaterstagesoftheirlives,theirnatural ‘PrimaryCareHome’(Colin-Thomé,2011). At best, primary care provides places inwhichindividualsareknown,andtowhichtheychoosetogowhen seeking to cope with health related challengesbecausetheytrustthattheywillreceivegoodguidanceandsupport.Thereisevidencethatcompetentgeneralmedical practitioners manage risks and identify self-limitingconditionsthatdonotneedfurtherinvestigationwith a relatively highdegreeof reliability, ascomparedto colleagues with more narrowly focused medicalexpertise.

PrimaryCareintheTwenty-firstCentury 3

Box 1. Good Primary Care

The development of consistent, person focused andtechnicallyrobustprimarycareservicesaimedatboththedeliveryofexcellent individualsupportandpublichealth improvement has for many decades beenrecognisedascentraltothepursuitof‘healthforall’.In1978,forexample,theAlmaAtadeclarationcalledonallgovernmentstoinvestinimprovingprimarycareasthecornerstoneofeffectivehealthservicesdevelopment.MorerecentlythecurrentDirector-GeneraloftheWHOnoted that international evidence overwhelminglydemonstrates that health systems oriented towardsprimaryhealthcareproducebetteroutcomes,atlowercosts and with higher user satisfaction, than morehospitalcentricsystems.

The available literature (see, for instance, Chambersand Colin-Thomé, 2008) identifies the hall-marks ofgoodprimarycareasincluding:

•comprehensive first point of contact care that isconvenientlyaccessibleforallmembersofacommunity,andwhichcoversallcommonhealthneeds;

•continuouspersonandfamilyfocussedcare,consistentwithindividualrequirementsforprivacyandchoice;

•theeffectiveandsystematicmanagementofchronic/longtermdiseases;

•referral to and the coordination of outpatient andinpatientspecialistcareasandwhenappropriate;and

•careforthehealthofentirepopulationsaswellasthatofeachpersonwithinthem.

In countries like the UK today high quality primaryprovisionalsoinvolvesmedicalandpharmaceuticalcareinresidentialhomes,andthecapacitytooffertailoredsupport to ethnic minorities. However, although thecentralityofgoodprimaryandassociatedcommunitycareandpreventiveservicesiswidelyacknowledged,thereareoftenpressuresthatcanservetodrawfundsawayfromsuchareasintohighercostsecondaryandtertiarycarecentres.

Further,eventhoughresearchindicatesthatmostNHSprimary medical care is of good standard there arenevertheless reasons to believe that further progresscouldbemadeinareasrangingfromprescribingandhelpingpatientstakemedicinestobesteffectthroughto improving early stage disease diagnosis and thebetter coordination of home support. Better jointworkingbetweenhealth professionalswho are eitherco-locatedorworkingingoodcommunicationacrossdifferentsitescancontribute tosuchgoals,providingallthoseinvolvedareadequatelymotivatedtoimproveoverallhealthandsocialcareoutcomes.

Figure 1: Primary Health and Social Care Figure 2: The Direction of Health Care Development

Community pharmacy’s opportunity

Helping people to stay healthy and live well

Institutional care, suspended social roles

Community care, normal social roles

The future of modernised primary medical and community nursing care?

The traditional focus ofmedical power - hospital care

Treating seriously ill patients

Dispensing and pharmaceutical

care

Source:theauthors

Note: Population ageing and allied factors will increasingly focus the work of primary care doctors and nurses on supporting people with serious and complex health problems who are living as normally as possible, whether or not they are in receipt of residential care.

Community pharmacy has an opportunity to support this transition and to extend its role to include self care support, risk factor management and first contact health care provision for common conditions.

Source:theauthors

Self Care/ Self Management

Primary Prevention

Day to day Health Care and Disease

Diagnosis and Acute and Urgent

Care

A&E Admission

SpecialistCare

Secondary Prevention

Tertiary Prevention and Long Term

Condition Management

Self Care/ Self Management

Additional (non-health) Social Care

Palliative/End of Life Care


Aswellasprovidingdiagnosesandcaredirectly,acentralrole for generalmedical practice as a specialism is toefficiently manage risk and route individuals requiringinterventionsthatcannotbemadeinthepracticesettingtootherappropriateproviders(Forrestetal2006;Footetal,2010).However,GeneralPracticeisnotalwaysashighlyvaluedas itsproponentsbelieve itoughttobe.1Sociologically,thismayinpartbebecauseGPscanbeseenasbridgingthegapbetween‘scientificmedicine’and less technical, more personal, forms of care andsupport.

ButevenifistruethatGPsbyvirtueoftheirroleshavestronger insight into thepsycho-socialneedsofhealthservice users thanmany hospital based professionalsandalso that thequalityofmostof their care isgood(Goodwinetal,2011), there is long-standingevidenceof difficulties and discontinuities in NHS primary andlinked Local Authority social care provision in relationto both physical andmental health. There ismuch tocommend NHS general medical practice. Yet overall

1 Famously,in1958LordMoran,thenthePresidentoftheRoyalCollegeofPhysicians,observedthattherewasacareerladderinmedicine,andthatitwasone‘offwhichthey[GeneralPractitioners]fell’.Despitetheprogressofthelasthalfcenturysuchnegativeattitudescanstillbefoundtoday,notleastamongstthemembershipsofsomehospitalTrustBoards.Similardividesexistinprofessionslikepharmacy.

standardsofcommunitycareoftenfallshortoftheideal,inpartbecauseofcoordinationproblems.Therearenowopportunitiestocorrectsuchfailings.

Questionsaboutprimarycarefitnessforpurposearenotnew.Theydatebacktothe1950sandbefore–see,forexample,the1920‘DawsonReport’andCollings,1950.Box2highlightssomeofthefindingsoftheseanalyses.Reformssuchasthoseintroducedviathe1966‘Doctors’Charter’(whichrestrictedthesizeofindividualGP‘lists’andencouraged increasedpractice staffingand largerGPpartnerships–atthattimeamajorityofBritishGPsstill worked alone or in two handed partnerships) andlatermeasuresliketheestablishmentoftheNHSinternalmarketsoughttostrengthentheNHSthroughenhancingprimary care and its capacity to play a central role indelivering services or guiding their improvement. Sotoodidthemorerecentcreation(inEngland)ofClinicalCommissioningGroups(CCGs)andNHSEngland.

Yet the extent to which such measures have beensuccessfulinachievingtheirdeclaredendsis–todate,at least–atbestquestionable.Aswith thepolyclinicsadvocatedduringthelastLabouradministration(Darzi,2008),suggestedformsofprogresshaveoftensoughttogenerateefficienciesviatheformationofbiggerprimarycare organisations and through service ‘integration’in the sense of co-locating GPs with not only wider

Box 2. From Dawson to Collings

Following the end of the first world war the thenLiberal politician Christopher Addison (a doctor whosubsequently became Leader of theHouse of Lordsduring the 1945-51 Attlee administration) sought totransform the then Local Government Board into anewMinistryofHealth.HebecamethefirstMinisterofHealthin1919.

Because of ‘austerity’ linked concerns about healthspendingAddison lost thispositionwithin twoyears,butnotbeforehehadcommissionedaradicalreportbytheRoyalphysicianandwarheroSirBertrandDawson(whobecameLordDawson)onthefutureprovisionofmedicalandalliedservices.Aninterimdocument,whichbecameknownastheDawsonreport,waspublishedin1920(Dawson,1920).Thisstronglyadvocatedtheformation of an integrated primary and secondaryhealthcentrebasedsystem.Althoughnofurtheractionwas instituted at the time, this pioneering analysissubsequentlyunderpinnedargumentsinfavouroftheformationofasystematicallystructurednationalhealthservice.

However,wheninpartduetothecontinuingeffortsofindividuals such asAddison theNHSwas eventuallyestablished in 1948 it pragmatically combinedarrangements that had independently evolved in theprecedinghalf century.Generalmedical practice andcommunitypharmacywere (alongwith localauthority

based service assets such as district nursing andpublichealthexpertise) importantelementswithintheoriginalNHS.But theywere not joined together in awell-coordinatedmanner,andtheirqualitywasatbest‘patchy’.

The latter fact was highlighted in 1950 by a surveypublished in the Lancet by an Australian doctor andqualitative ethnographic researcher called JosephCollings(Collings,1950).Hehadbeencommissionedby the Nuffield Trust to assess the state of generalmedicalpracticeintheNHS.

In fact his work was never fully published. Yet whatdid become available revealed many reasons forconcernaboutthethenisolatedandpoorlysupportedsituation of GPs. Collings judged general medicalpracticetobeananachronismwhichneededrapidandcomprehensivechange.Thisviewwasinitiallyrejected(Wilkie,2014).However,startingwiththeformationofthethenCollegeofGeneralPractice in1952andtheBMA published 1954 Hadfield report Good General Practice, it in time opened the way to fundamentalreform via an adaptive incremental process whichin contexts like the interfaces between communitypharmacy, general practice and community nursinghascontinuedthroughtothepresent.


multi-disciplinaryhealthandsocialcareteamsbutalsospecialistphysicians.Thepursuitofperformancegainsviathemoreassertivemanagerialplanninganddirectionof professional work has typically been implicit in thissortofapproach.

TherehavealsobeenmultipleeffortstofurtherdevelopcommunitypharmacyandnursingservicesinEngland,ScotlandandtheotherUKnations. (See, for instance,Clukas, 1986; DHSS, 1986; DoH, 2000; ScottishExecutive, 2002; Smith et al, 2013, 2014.) But thedegreetowhichsuch initiativeshave in realityenabledNHS primary and LA social care providers to worktogether in less fragmented, more efficient, ways andadaptpro-actively to thechangingrequirementsof thepeople they serve is again questionable. Inadequatelycoordinated approaches represent a significant barriertoimprovingoutcomesinareassuchasprovidinghighquality,affordable,servicesforolderpeoplewithcomplexcareandsupportneeds(Humphries,2015).

Atworst, someNHS improvement attempts could beaccused of being based on ‘magic thinking’, ratherthan carefully evaluated evidence and well-designedimplementation strategies. Some of the professionalsinterviewed during the preparation of this report saidthat declining primary and community care resourcesrelative to NHS total spending, coupled with risingpatientdemands,unwantedorganisationaldisruptions,increasingbureaucracyandashortageofyoungdoctorswillingtoentergeneralpractice,meanthattoday‘it has never been more difficult to be a GP.’ However,anotherveryexperienceddoctorsaid‘I cannot remember a year when there was not low morale – its normal’.

There is also evidence of pharmacist and communitynursing discontent, albeit NHS services have to datebeenmuchbetterprotectedfrom‘austerity’thansocialcareandotherLocalAuthorityserviceslike–forinstance– ongoing adult education for people with learningdisabilities.Claimsoftherebeingacrisisinprimarycare,orintheNHSmorewidely,shouldthereforebeviewedwithsomecaution(Dayanetal,2014).Theyareinpartlinked to conflicts about whether or not UK (public)healthcare fundingshouldbestrictlycash limited thatdatebackatleasttothestartofthe1950s,andmightevenbe linked to a national debate that began in theaftermathofWorldWar1.

Suchdisputesshouldarguablyberegardedasnormalindemocraticallyled,politicallycontrolled,environments.Onsomeoccasionsfundingandperformanceproblemsmay be over-stated, and on others they have beenmisstated. The NHS has often been characterisedbywhatappear tobescandal ledchangesor ‘shock’reorganisations, rather than well directed incrementalevolution.

However,eveniftheunderlyinghealthservicesituationis more robust than is sometimes suggested, thereare from a patient perspective substantive primarycare linkedproblemsrangingfromthetime itcannowtaketogetaGPappointment(especiallywithadoctorwho has a personal relationship with the individualseeking attention) through to fears that theGPbasedapproaches may, especially in contexts where therearestrongdemandsfortheavoidanceof‘unnecessary’diagnostic testing costs, undesirably slow access totimely specialist advice. Poor quality primary care canalso discourage health service users from pro-activelyseekingtoprotecttheirhealth,andsoaddtolongtermcostsand/orhealthloss.

Negative approaches to health care demandmanagementmaymakepeoplefeelthattheyshouldnot‘bother’healthprofessionalswithwhatareprobablyminorproblems,butcould inaminorityof instancesbeearlymanifestationsofseriousdisease.Theconsequencesofsuchphenomenahave includednotonly relatively lowratesofearlystagediseasediagnosis infieldssuchascancercare,butamorewidespreadneglectof ‘trivial’health issues that can in some cases herald disabilityor life threateningeventsassociatedwith, forexample,underlyingvasculardisease.

ThereissomeevidenceofsuchfailingsintheworkingofotherstronglyGPcentredhealthcaresystems,likethatofDenmark(OECD,2015).Asnotedabove,therehaveinBritainalsobeenproblemsrelatingtotheco-ordinatedprovision of primary medical care with other forms ofcommunity health and social service support. Suchphenomena link inpart to the fact thatLocalAuthoritysocialandalliedcareprovisionwasnotmade‘free at the point of demand’ in theway thataccess toNHScarewasguaranteedaftertheendofWorldWarII.

Withthedeclineofinfectiousdiseaseandtheconsequentrise of non-contagious disorders of later life the needfor services that facilitate satisfactory independentliving despite their users having to cope withmultiplemorbiditieshasrisen.ComparedwithmostifnotallotherhealthcaresystemstheNHShasmetthischallengewell,withintheboundariesoftheresourcesmadeavailablebysuccessive governments (WHO, 2015).But even so itisarguablythecasethatclinicallyandsociallydesirableprogresscouldhavebeenachievedfaster.

TheexistenceoftheNHScouldinsomeinstanceshavehidden ongoing failings in service areas that lack thesocialstandingofspecialisedmedicine.Thecreationofauniversalhealthservicein1940sBritainwasintendedtosweepawaytheheritageoftheVictorianPoorLaw.Ithaslargelyachievedthisgoal infieldslikethesupplyofmostmedicinesandbasicaccesstodoctors.Yettherecordof theBritish system in supportingpeoplewithhealthandrelatedproblemsassociatedwitheconomicdisadvantage and daily living difficulties does not


compareaswellasmightsometimesbehopedwiththatofEUcountrieslikeTheNetherlands,France,Germanyand Sweden. Such realities help to account for therelativelymodest rankingof theUKonscalessuchastheEuropeanHealthConsumerIndex(EHCI,2014),andmaypartiallyexplainthepersistenceofreduciblehealthinequalitiesdespitethe‘welfareState’.

Relationships and cultures that deliver better health

There is research showing that many people facingserious health challenges wish their GPs to be theprimary co-ordinators of their treatment and support,andthatmostGPswishtoplaythisrolewell(Parsonsetal,2010).YetinrealitytheabilityoftheexistingNHSandsocialservicessystemtodelivercomplex,multi-facetedcareinthecommunityandtohandletransfersbetweendifferent hospital and other service providers in timely,convenientand‘userfriendly’waysisoftenlimited.

GPs frequently report that they cannot always investthetimeandotherresourcesneededtocoordinatethesupport required by vulnerable individuals. But manyalso seem unable or unwilling to pass this role on tocolleaguessuchascommunitymatronsordistrictnursesinatimelymanner.Similarpointsapplyincontextslikethe management of vascular disease risks, and theextended part that professionals such as communitypharmacistscouldplayinthisandalliedfields.

Such observations ought not to obscure the realitiesof service under-funding, as and when they exist.Nevertheless, there is a case for saying that GeneralPractitioners and Community Pharmacists could,together with the other professional groups providingprimary health and social care, in future do more tohelp improve the quality of services by overcomingsectionalconcernsandstrengtheningcommitments to‘integrating’ carebyworking togethermore effectively.Regardless of structural issues or even financialincentives,appropriateethical imperativesareessentialforthedeliveryofadequatelycoordinatedprimarycareintoday’senvironment.

SomecriticsarguethatGPstendtoover-emphasisetheimportance of services under their immediate control,and fail tosupportadequately thedevelopmentof theprimary care system as a whole. At the same timeCommunityPharmacists(CPs)canappear–atleasttosomeobservers–tobeundulyconcernedwithprocessesofdrugsupplywhichmaynotbeoptimallycosteffectivefromapublicinterestperspective,oralwaysidealfromaconsumerconvenienceviewpoint.

It may also be suggested that hospital orientedprofessionals and managers are on occasionsinadequately informed about the role of primarycare, and can fail to act in the best overall interestsof the communities they serve because of an (albeitunderstandable) desire to defend ‘their’ institutions asfree-standingentities incompetitionwithotherpartsofthehealthservice.Suchphenomenamight,forexample,underpinoppositiontoformsofprimarycareledbudgetholding that their advocates believewould allowmoreflexibleandbettermanagedapproachestothedeliveryofNHSpatientsupportacrosscommunityandinstitutionalboundaries.

AssuringthestabilityandsustainabilityofNHShospitalservicesisimportant.Butitwouldbeself-defeatingifthisweretobepursuedinwayswhichunderminethecapacityofthehealthservicetoofferthebestpossiblecarewiththe global financial, technical and human resourcesavailable, andmake it needlessly difficult for desirablechangetobeachieved.Determiningthe‘right’numberofhospitalbedsandthemarginalcostsandbenefitsofreducinginpatientcarecapacityorotherformsofserviceatanyonepointintimeisacomplexandoftenuncertaintask.Butlongtermprogresswillprobablyrequirerelativeincreasesintheprovisionofthefullrangeofcommunitybasedfacilities,alongsidecontinuingadaptationsintheconfigurationofspecialistservices.

‘Pharmacy first’?

Againsttheabovebackground,thisreportconsidersthedevelopmentofprimarycareinthecontextoftheNHSas a whole, and the changing health and social carerelatedneedsandabilitiesofthecountry’spopulation.InthelightofNHSEngland’sFive Year Forward View (theFYFV–NHSEngland,2014)andrecentinitiativessuchastheNationalAssociationforPrimaryCare’ssupportforthePrimaryCareHomeconcept(NAPC,2015)andthejoint NAPC/Royal Pharmaceutical Society consultation‘Improving patient care through better general practice and community pharmacy integration’ (NAPC and theRPS, 2015), it considers aspects of the relationshipsbetween GPs, community pharmacists, communitynursesandotherprimarycareproviders.Italsoexploreshowfurtherimprovementsintheircollectiveperformancemightbestbepursued.

GivenfactorssuchasemergingITbasedopportunitiesfor enhancing processes like providing information,diagnosingmentalandphysicalillnessesandprescribingand dispensing medicines, this analysis in additionaddresses questions relating to how independentlylocated community pharmacy services can contributefurther to the promotion of self-care and provision ofbetter co-ordinated andmore affordable primary care.Givenfinancialpressuresand theongoing introduction


of‘constructivelydisruptive’healthtechnologies(EXPH,2015)andnewconsumerdemands,continuinghealthsector change is inevitable. A fundamental challengeforprofessionals likeGPsandcommunitypharmacistsrelatestotheextenttowhichtheywillbeabletoplayapositive role inactivelyshapingnewmodelsofservicegovernanceanddelivery.

Oneofthemainfindingsofthisreportisthattheexistingcommunitypharmacynetwork isaresourcethatcouldandarguablyshouldbedevelopedinwaysthatwillallowit togoonsupplyingmedicines incosteffectiveways,whilealsooffering‘firstcontact’accesstoclinicalcareinthecommunityinaprogressivelymoreefficientmanner.Failures to establish and implement a strong visionfor Community Pharmacy alongside that for GeneralPractice could threaten theNHS as awhole, and theinterestsofthepublicitserves.

Future progress will almost certainly challenge thetraditional demarcation linesbetweenmedical, nursingand pharmacy practice and weaken the bordersbetween prevention and treatment, as well as thosebetween professional support and self-care. Otherdevelopments in the organisation, management anddelivery of professional services will also be needed,including(probablyifnotcertainly)increasesinthescaleand complexity of primary or integrated primary andsecondarymedicalcareorganisationsandtheircapacitytostreamlineservicedelivery.

However, as thework of economists such as JosephSchumpeter (1942) and Ernst Schumacher (1973)has in the past highlighted, the relationship betweenorganisational size and variables such as innovationand personal service quality and satisfaction is notstraightforward. Inadequately considered changes canhave perverse results. There are costs to, as well asefficienciesof,increasedscalethatshouldbebalancedagainst the overall benefits provided for communities,individual service users and ‘hands on’ providers. Atworst,creatinglargerorganisationscanservesectionalmanagerialends,asdistinctfrompublicinterestsinbetteraccesstopersonallyfocusedprofessionalsupport.

From Medical Dominance to Managed Care?TheformationoftheNHSin1948waspartiallyinspiredby the Soviet Union’s pioneering attempts after 1918to establish, in very much harder circumstances thanthosefacingBritainatanypointinthetwentiethcentury,a universal health care system. Yet the establishmentof theNHSwasnota ‘nationalisation of the means of health care production’ like that of the railways andother keyutilitiesundertakenby theAtleegovernmentduringBritain’s late1940spost-war recovery. Itsmostprominent immediatearchitect,WilliamBeveridge,wasaLiberal,andtheconceptofuniversalhealthcarewasstrongly supportedbyConservatives such asWinstonChurchillandHenryWillinck,England’swartimeHealthMinister.AneurinBevan,whoasasubsequentLabourMinisterrejectedtheBismarkiansocialinsurancemodeland favoured a tax funded National Health Service,described the creation of the health service as anexampleof thepracticalapplicationofChristianvaluesratherthanasanachievementofsecularsocialism.

Voluntary, private and previously Local Authority runinstitutions were taken into public ownership in 1948andcombined to formaunifiedNHShospital service.However,theTeachingHospitalsretainedaspecialself-governing status, and the National Health Service asoriginally formed was a tripartite structure. It includedpractitioners such as GPs, community pharmacists,dentists and opticians who were independentlycontracted to the Minister of Health and who ownedtheirpremises,aswellastheLocalAuthoritycontrolledand funded district nursing, health visiting and publichealthservices.

Thesecommunitybasedresourceswereno lessapartof the overall NHS system than the nationally ownedhospitals, although the structure of the new serviceperpetuated the ‘gate keeping’ divide between primaryandsecondarycarethathadexistedinBritishmedicinefrom the last decades of the nineteenth century. In theCommunity Pharmacy sector the new health serviceadoptedamixedcorporatelyandindividuallyownedretailmodelthathadalsoemergedinthelateVictorianera.

InitsinitialdecadestheNHSwasnotstronglymanagedbyindividualsotherthanhealthprofessionals,amongstwhom the medical profession was indisputablydominant. Further, its financial resources were in themain allocated on an incremental basis, rather thanvia either a competitive or a robustly supported ‘non-market’process.Mostofthereformsintroducedinthelast60-70yearscanbeseenasattemptstobetterplan,manageandco-ordinatecareprovisionofferedbyeithertheNHSalone,orbytheNHSandLocalAuthoritiesincombination.ThetimelineofferedinFigure3highlightssome of themajor steps involved in the development


Figure 3. The Evolution of the NHS in England – an Outline Timeline

1942-46 SirWilliamBeveridge’sreportSocial Insurance and Allied Services proposedthecreationofthemodernwelfareStateandtheestablishmentoftheNHSin1942,althoughtheconceptofaNationalHealthServicedatesbackto1910.AWhitePaperwaspublishedbythewartimecoalitiongovernmentin1944andtheNHSActwaspassedin1946,ayearafterAneurinBevanbecameMinisterforHealth.

1948 TheNHSisestablishedwiththeopeningofParkHospitalinManchester

1949 TheNursesActsoughttoestablishanewbasisfornursing,andconcernsabouttheaffordabilityoftheNHSwereexpressed.

1950-56 JSCollingsfoundthat‘the overall state of general practice is bad and still deteriorating’.Aoneshillingprescriptionchargewasfirstleviedin1952,andinitialattemptsaremadetopromotetheformationofgrouppractices.In1956theGuillebaudInquiryfoundthattheNHSwasaffordableandthattherewasnoevidencethatitsestablishmenthadledtoextravaganthealthcarespending.

1962 EnochPowelllaunchesaplaninvolvingtheestablishmentofdistrictgeneralhospitalsservinglocalpopulationsofabout125,000people

1966 The‘Doctor’sCharter’introducesnewincentivesforthedevelopmentofbetterstaffedGPpractices

1974 ThefirstmajorNHSreorganisationseekstoputinplaceaunitarystructureinvolving90HealthAuthoritiesinEnglandand14RegionalHealthAuthorities.However,theExecutiveCouncilsthatpreviouslyadministeredfamilypractitionersservicesarereplacedbyFamilyPractitionerCommitteesthatcontinuedtofunctioninrelativeisolation.CommunityHealthCouncilswerecreated.Theyenjoyedasignificantdegreeofcriticalautonomy.Functionssuchasdistrictnursingandpublichealthareremovedfromlocalgovernment,butsocialserviceprovisionremainsunderLAcontrolandisinhealthcontextsubjecttocharges

1976 Sharing Resources for Health in England signalsanewapproachtoNHSresourceallocation

1983 TheGriffithsReportmarkedtheintroductionofgeneralmanagementintheNHS,althoughitsimpactonprimarycaredevelopmentisrelativelylimited

1986 Neighbourhood Nursing: a Focus for Care andtheNuffieldreportPharmacyraiseimportantquestionsaboutthefutureofcommunitynursingandcommunitypharmacy.However,progresstowardsmoreeffectivelycoordinatedserviceprovisionremainslimited.

1989-91 FollowinganinterventionbyMargaretThatcher,theWhitePapersWorking for Patients andCaring for Peopleleadtothe1990NHSandCommunityCareAct.TheNHSinternalmarketwithGPFundholdingandmoreautonomoushospitalTrustsatitscentrewasestablishedin1991.

1997 TonyBlair’snewlabourgovernmentmovesrapidlytoendGPFundholdingandtheWhitePaperThe New NHS: Modern, Dependablepromisesanon-marketapproachbasedoncollaborationratherthancompetition.ItalsoopensthewaytotheestablishmentofNICEandwhatistodaytheCQC

1999 TheshortlivedbutrelativelypopularPrimaryCareGroups(PCGs)weresetup

2000-02 TheNHSPlanispublished,withproposedhospitalserviceimprovementstobefinancedviathePrivateFinanceInitiative.NHSfundinggrowthisaccelerated,andPrimaryCareTrustsreplacePCGswiththeintentionoffurtherdevelopingtheutilityoftheNHSpurchaserproviderdivide.SecretaryofStateAlanMilburnannouncedplanstointroduceFoundationTrustsin2002,andpotentially‘awkward’CHCswereabolishedin2003

2006-2009

Our Health, Our Care, Our Say: a new direction for community services seekstopromotethedevelopmentofbettercoordinatedprimaryhealthandsocialcare.TheRCGPfirstproposestheformationofGPFederationsandLordDarzisubsequentlyleadsareviewcallingforgreaterserviceintegrationandincreasedclinicianinvolvementinhealthcarequalitymanagement

2010-12 ThenewcoalitiongovernmentpublishesEquity and Excellence – Liberating the NHSwhichleadsontothe2012HealthandSocialCareAct.ThisinvolvestheabolitionofPCTsandtheformationofClinicalCommissioningGroups(CCGs)aswellasarangeofotherinnovations,includingtheestablishmentofNHSEnglandandPublicHealthEngland

2013 SirRobertFrancispresentsthefinalreportoftheMid-StaffordshireNHSFoundationTrustPublicInquiry

2014 TheFiveYearForwardView(FYFV)setsoutNHSEngland’sstrategicapproachtoquestionssuchasreducinghealthinequalities,improvingcarequalityandmeetingprojectedhealthandsocialcarefundingshortfalls.Ithighlightsthepotentialroleofnewcareproviderssuchasmultispecialtycommunityproviders(MCPs)andprimaryandacutecaresystems(PACs)perhapsrunalonglinesparalleltothosedevelopedbyUSaccountablecareproviders.

2015 TheNationalassociationforPrimaryCarepublishesits‘PrimaryCareHome’proposals,andtheNAPCandtheRoyalPharmaceuticalSocietyconductajointconsultationoncloserworkingbetweencommunitypharmaciesandgeneralpractices.NHSEnglandannouncessupportfortheemploymentofmorepharmacistsinpractices,butitbecomesclearthatthecaponprivatesocialcarecostsproposedbytheDilnotCommissionin2011willnotbeimplementedintheforeseeablefutureandthatanincreasingcrisisinlocalauthorityfundedsocialcareprovisionisputtingincreasinglyseverepressuresonNHSTrustfinances.TheNovember2015ComprehensiveSpendingReviewledtotheannouncementofincreasedfreedomsforEnglishlocalauthoritiestofundsocialcareviaraisedCounciltaxes.AnNHSbudgetincreaseof£4billionwasalsoannounced,inlinewithNHSEnglandrequests.


ofprimarycarewithinthewiderevolutionof thehealthserviceinEngland.

The British Medical Association originally opposedthe creation of the NHS, along with sections of thenational press. Some doctors’ representatives fearedan undermining of medical authority and income. Yetfollowing the establishment of the new health servicedoctors found themselves able to retain substantivecontrolovertheirwork,andhencetoplayacentralroleindirectingtheuseofitspubliclyprovidedfunds.Atthesametimetheabilityofspecialisteliteswithinmedicineto, especially in London, accrue additional privateincomeremainedintact.

Eveninthe1960sHealthMinisterssuchasEnochPowellcouldsetpolicyatastrategiclevelinrelationtomatterssuchastheconfigurationofhospitalcare,yethadlittleimpactontheconductofday-to-dayprofessionalwork.Hospitaldoctorswerecontractedtoregionalauthoritiesrather than the institutions inwhich theyworked.GPswere individually contracted to the Minister of Health,albeittheirday-to-dayaccountabilitiesforservicequalitywere in themain to theirprofessionalbodiesand toalesser extent to the Executive Councils that at thattimeadministered their payments, alongwith those tocommunitypharmacies,dentistsandopticians.

Thisperiodhas–particularlyinrelationtohospitalcare–beendescribedasoneof‘medicaldominance’,andasa‘goldenage’formedicine(Burnham,1982;McKinlayandMarceau,2002).NHSpatientsnolongerhaddirect‘powerofpurse’over thoseproviding themwithcare,whilenon-clinician ledhealthservicemanagementhadyet to emerge in its modern form. Doctors decided,patientscompliedandtaxpayerspaid.Notwithstandingfundingsystemvariations,muchthesamestateofaffairsexistedinothercountriesatthattime,includingtheUS(Freidson,1970a,1970b).

However,thissituationbegantochangeintheUKwiththe first major NHS reorganisation in 1974 and thesubsequent introduction during Margaret Thatcher’spremiership of (following the 1983 ‘Griffiths Report’)general management and the NHS ‘internal market’.It was also at the start of the 1980s that the thenHealth Minister Dr Gerard Vaughn began questioningthe prescription medicines supply rather than patientcarefocusedroleofNHScommunitypharmaciststhatemergedfromtheendofthe1940s.

Hospital pharmacy began to take a more pro-activeclinical–oratleastdrugsafetyoriented–roleinthewakeoftheThalidomidetragedyatthestartofthe1960s.ButNHS Community Pharmacy had become increasinglycentredonhighvolumeprescriptionmedicinessupply.Atthe1981BritishPharmaceuticalConferenceVaughncommented ‘one knew there was a future for hospital pharmacists, one knew there was a future for industrial

pharmacists, but one was not sure that one knew the future for the general practice [community] pharmacist’(Anderson,2007).This intervention ledtoaprocessofrolereassessmentwhichhascontinuedthroughtothepresentday.

GP Fund-holding

GP Fund-holding was first established in 1991. TheNationalHealthServiceandCommunityCareAct1990alsocreatedmoreindependentHospitalTrusts,governedby chief executives andBoards and towhichmedicalconsultants were for the first time directly contracted.NHSTrustsovertimebecamemorelikeprivate‘forprofit’institutions. As the NHS record on service integrationand thecarequalityproblems revealedby theFrancisInquiry (2013) indicate, this approach has had mixedoutcomes(Lester,2015).Whilemanyaspectsofserviceprovisionhavebeenimprovedbythenon-medicalNHSmanagerialismthathasevolvedsincethe1980s,failureshaveonoccasionsharmedcarequality.The1990Actmay also have exacerbated aspects of the NHS andsocial care funding divide, so perhaps creating newincentives to cut back in areas like NHS communitynursing.

BothGPFund-holdingandNHSTrustswerecentraltoforming a more market-like system of NHS resourcedistributionandservicedelivery.However,thanksinparttothedemandsofcompetitionlawandthequestionablylogical continuation of the NHS ‘purchaser-providerdivide’ after GP Fund-holding was abandoned, thecostly, complex and highly bureaucratised manner inwhich NHS ‘internalmarket’ contracting subsequentlydeveloped was not in line with its early advocates’intentions. Money was supposed to ‘follow patients’,whosecarewasintendedtobeincreasinglytailoredtotheir personal needs. But in reality, critics argue, carepatterns became determined by rigid contracts and apurchasing/commissioning process that tended to becentered on cost control and basic standard settingratherthancreativequalityimprovement(Box3).

Upuntiltheendofthe1980sGPscouldreferpatientsmoreorlessfreelytothehospitalcareprovidersoftheirchoice.Yet theadequacyof themechanismsthathadevolvedforcompensatinghospitals forchanging levelsof service use was limited, and there were also fearsthat general practitioners had inadequate incentive tokeep people out of hospitalwhen their care could bebetter provided at the practice level or in other lesscostlysettings.Fund-holdingwas intended toaddressboth theseproblems, inpartbyencouragingGPsandtheirpracticecolleaguestoadoptapro-active‘makeor


buy’ approach to supplying services for their practicepopulations.2

A variety of alternative solutions to resolving theseproblemsmighthavebeenselectedat thestartof the1990s. For example, a non-market approach could(in some ways like the Scottish NHS system today)have involved improving systems for monitoring andevaluatingprofessionallydeterminedGPreferralpatternsand adjusting centrally directed hospital resourceallocations to reflect local preferences and nationalserviceimprovementpriorities.

However, one positive effect of the seven year GPFund-holding ‘experiment’ that tookplace inEnglandbetween 1991 and 1998was that the practices thatsuccessfully took part in it (along with the ‘multi-funds’ and ‘total purchasing pilots’ that emerged)demonstrated–atleastwithintheprimarycarearena,if not so clearly in the hospital sector – the potentialof devolved GP led ‘purchasing’ to deliver desirableserviceimprovementsinrelativelybriefperiodsoftime.

2 BothduringtheGPFund-holdingeraandsubsequentlyinthecaseofCCGcommissioningGPshaveonoccasionsbeenaccusedofimproperly‘payingthemselves’toprovideadditionalservicestotheirpopulations,sometimesbyoronbehalfofinterestsseekingtosecureincreasedearningsfortheirowncompaniesorTrusts.Butprovidedallinterestsareproperlydeclaredanddecisionsareatduepointsauditedtoensureprobityandcosteffectiveness,thisiswhat‘ACOtype’localbudgetholdingisintendedtoachieve.Whereitischeaperandbetterprimarycareprovidersshould‘make’servicesthemselves.Inothercircumstancestheyshouldbuythemfromothersasefficientlyaspossible.

Fund-holdingbyapracticeorpracticeswas foundatthe time to incentivise the imaginative use of moneythatwasnottiedtoparticulardiseaseorcaregroupsforthebenefitoftheindividualsandentirepopulations.(See, for instance, leGrandetal,1998;BreretonandVasoodaven,2010).

Yet despite its positive dimensions, GP Fund-holdingwasunpopularwiththethenLabouroppositionandwiththeBMA,aswellaswithsectionsoftheGPcommunityitself. It is sometimes claimed that Fund-holdingdivided General Practice, albeit in reality it can moreaccuratelybesaidthatitrevealedimportantdifferencesin leadership and care delivery capacities that alreadyexisted. In addition, somehospital staffmembers andNHS managers involved in the nascent process ofinstitutionalised(contractbound)commissioningsawGPFund-holdingasathreat.ItwasconsequentlyabandonedsoonafterthestartofthefirstBlairadministration,whichwaselectedtopowerin1997.

Opponents of what was sometimes termed ‘NHSmarketisation’welcomed thisstep.Yet itwas followedby a series of other attempts to harness market-likemechanismswithinthehealthservice.Theseeventuallyled to the establishment of Primary Care Trusts(PCTs),and initiatives intendedtodevelop ‘worldclasscommissioning’ skills and topromote the formationofFoundationTrusts.Thisseeminglyrelentlessprocessofchangewas,ithasoftenbeenclaimed,responsiblefor

Box 3. Quality Management

Thehistoryof‘qualitymanagement’datesbackoveracentury,toworklikethatoftheAmericanFrederickTaylorandtheconversionofcraftworktomechanisedfactoryproduction.Thiswasfollowedbythecontributionsofpioneers like Walter Shewhart of the Bell TelephoneCompanyonprocessqualitycontrol,andsubsequentlythatofpostWorldWarII‘qualitygurus’suchasWilliamEdwards Deming, Joseph Duran, Kaoru Ishikawa,ShigeoShingoandTomPeters.

Suchcommentatorsintroducedconceptsrangingfromtheneedto ‘driveout fear’ in ‘learningorganisations’(based on the belief thatmost people want to do agood job, and that performance monitoring andfeedback should therefore be supportive ratherthan punitive) through to ‘just in time delivery’, ‘totalquality management’, ‘continuous performanceimprovement’, ‘businessprocess re-engineering’ and‘transformationalleadership’.

Well known examples of attempts to apply suchthinkinginhealthcarerangefromtheworkofFlorenceNightingale during and after the Crimean War to, inthe twentieth century, the contributions of Dr AvedisDonabedian and more recently those of Dr DonBerwick. The creation of bodies such as NICE and

whatisnowtheCQCstemmedfromattemptstoapply‘qualitymanagement’concepts to the runningof theNHS.

Forthepurposesofthisanalysistwopointsareworthspecialemphasis.First,althoughqualitymanagementtechniquescanreleasesavingsthrough, for instance,reducing waste associated with redundant activitiesand concentrating effort on meeting external andinternal ‘customers’ highest priority requirements,there is robust evidence that if cost savingbecomesaprimarygoalthisoftenresultsinaspectsofproductandservicequalitybeingundermined.

Second, actions which devalue the status andundermine themotivation ofworkers are in any fieldlikely to have similar detrimental consequences. Inhealth and social care systems good managementis essential. But over-management is dangerous. Ifmanagerscometoseethemselvesandtheirinevitablysectional objectives as more important than peopleusing health and social services or more legitimatethantheprofessionalgoalsofand judgementsof theclinicians and other individuals delivering care, theirefforts will almost certainly have counter-productiveconsequences.


underminingGPandwiderhealthsectormoraleduringthefirstdecadeofthecurrentcentury.

‘Serial change’ was commonly experienced asdisruptive and lacking adequate justification. Butalongsidethesestructuralchanges,NHSfundingwasdramaticallyincreasedinthefirstdecadeofthetwentyfirst century (Figure 4). Public satisfaction with theNHSroseinlinewithbetterresourcing,thatgraduallytook NHS funding as measured by the proportionofGDPdevoted tohealthclose to theOECDmean.This allowed improved service quality, as indicatedbymeasures like reduced waiting times for hospitalcare. Developments were also introduced in areassuchascommunitypharmacy.Thesetooktheshapeof services like ‘minor’ ailment treatment schemes,pharmacist led repeat dispensing arrangements andMedicinesUseReviews(MURs).

However,thereisnoevidencethatsuchinnovationshave–althoughuseful – todate fundamentally transformedprimary care performance. It can be argued that afterthe formation of PCTs the extent to which local GPsand other primary health care professionalswere abletoplayeffective localroles infindingandimplementingradicallybetterwaysofmeetingchanginghealthneedswas in factdiminished.3SomePCTswereregardedassuccessful.Butotherswereseenaslackingtheinsightand capabilities needed to promote better serviceprovisionthroughcommissioning.

3 ItisalsoofnotethatduringthefirstBlairadministrationdecisionsweremadebothtoreplacethebythenwell-establishedCommunityHealthCouncils(thathadoriginallybeencreatedvia1974NHSreorganisation)andtostopregularcontactbetweenNHSTrustandAuthoritychairpersonsandthethenSecretaryofState.AlthoughpresentedinwaysthatsuggestedaconcernforNHSdemocratisationandconsumerempowerment,suchactionsmightalsobeconsideredconsistentwithadesiretoimpedemoreforceful‘bottom-up’policychallenges.

The coalition government elected in 2010 was notinitially expected to introduce further major structuralchanges in the NHS. Hence the far reaching reformplanspublishedlaterthatyearintheEnglishWhitePaperEquity and Excellence: Liberating the NHS were formanyashock.Thenewarrangementseventuallysetoutinthe2012HealthandSocialCareAct(thatcameintofulleffectinEnglandinApril2013)wereintendedbythethenConservativeSecretaryofStateforHealth,AndrewLansley, toprovidedefinitivesolutions to theproblemsfaced by the NHS. Yet regardless of their theoreticalstrengthsandweaknessestheirimplementationranintoavarietyofdifficulties.

It would be beyond the scope of this brief outlineto attempt to describe in detail the development ofthe NHS in the last two to three years. However, theremainder of this section offers observations relatingto theongoingevolutionof theprimarycaresystem inEngland,withspecialrelevancetogeneralmedicalandpharmaceutical care andproviding community nursingandsocialservices.

Health service spending

TotalUKNHSfundingrosefrom3.5percentofGDPin1949toabout8.5percentofGDP in2013/14.Therewasasalreadydescribedparticularlyrapidgrowthintheperiodbetweentheendofthe1990sand2009.SincethenNHS outlays have slightly fallen as a percentageof total national resources, although in 2016 theyshould recover again following recently (November2015)announcedincreasesinhealthservicefundinginEngland.Atthesametimeoverall localauthoritysocialcarespending–whichbroadlyaccountsforanadditional1percentofGDP–hasreducedsince2008-09.

Health and Social Care Information Centre estimates(HSCIC,2015c)indicatethatoutlaysonadultsocialcareforthepopulationagedover65willhavedroppedinrealtermsbyabout15percentbetweenthenand2015/16.ThistrendhasincreasedpressuresontheNHS.InfuturetheabilityofLocalAuthoritiestoincreaselocalcommunitycharge payments to help fund enhanced social careshouldhelpstopthisdecline.However,thisaloneunlikelytorestoresuchprovisionstopastlevels,letalonetomatchScandinavianpublicinvestmentsincareforgroupssuchasmentallyandphysicallyfrailolderpeople.4

Withinthehealthsectortotal,FHS/primarycarespendingfell fromaround a third of allNHScosts in the 1950stoaboutafifthtoday.Thishasinpartbeenbecauseofincreased private payments for ophthalmic and dentalservices,andalsobecauseofrelativefallsincommunity

4 CurrentnegotiationsbetweencentralandlocalgovernmentmayalsobetouchingonissuessuchastheextentofLAlandholdings,andthedegreetowhichsuchcapitalassetsshouldbeusedtofundcurrentoutlaysinareassuchasresidentialandothersocialcareprovision.

Figure 4: NHS Funding GrowthRealNHSnetspend1970–2010

200

180

160

140

120

100

80

60 1 2 3 4 5 6 7 8 9 10

Yearofdecade

Inde

x(1styearofdecad

e=100

)

70s

80s

90s

00s

Source:Steer,2015

Note: real NHS funding in England grew by 5 per cent in the period between 2010 and 2015, which is a similar rate to that recorded for the NHS as a whole in the first half of the 1980s and above that in the second half of the 1970s. Recently announced expenditure increases in England mean that NHS funding will ultimately grow by 15-20% in real terms in the decade 2010-2020.


pharmaceuticalcostsassociatedwiththegenericisationofmanycommonlydispensedmedicines(Figure5).

GeneralMedicalService(GMS)costscurrentlyrepresentabout8percentofallNHSspending,orabout0.7percentofGDP.TheproportionofNHSfundsdevoted tothe GMS has declined as compared with five to tenyearsago(itstoodataround10percentofNHScostsin2004/5),albeittheGeneralPracticeworkforceislargerthanatanyprevioustime.BodiessuchastheRCGPandtheNAPChaverecentlycalledforspendingongeneralmedical care to be increased to 11 per cent of NHScosts. Spending on General Pharmaceutical Servicesnetofdrugcostscurrentlyrepresentsa littleunder2.5percentofallNHSoutlays.

Publicdebateabouttheextenttowhichhealthservicespending shouldbe increasedeach year in real termstomeetrisingcostscanbeconfusedbyfailurestotakeinto account variables like the impacts of increasedwages,asopposedtothosestemmingfromchangesindemandforcareandexpensesincurredasaresultoftheintroductionofnewmedicaltechnologies.However,itisworthhighlightingthefactthathealthserviceandalliedspending in theUK remainsbelow theOECDaveragewhenexpressedasapercentageofGDP.Itnowstandsatclosetohalf theproportionofGDPspentonhealthintheUSandaroundthreequartersofthatrecordedinGermany,FranceandTheNetherlands.

While‘higher’professionalsalariessuchasthoseforGPsand hospital consultants in the UK compare reasonablywell with reportedWestern European earnings, the totalnumbers of doctors and pharmacists employed by theNHSarerelativelylowascomparedwiththelevelsreportedincountrieslikeSpain,FranceandGermany.Atthesametime,spendingonsocialcareincountrieslikeSwedenandtheNetherlandsisover3percentofGDP, inadditiontotheirhealthcareoutlays.Thisfurtherincreasestheoveralldifference between health and social care spending inEnglandandotherpartsoftheUKascomparedwiththatinothermorehighlydevelopednations.

TheNHSremainsinglobaltermsoneoftheworld’sbestresourcedandrunhealthcaresystems.Yetthefactthatitpioneeredservicedeliverythat isstill inthemainfreeatthepointofdemandandfundedbygeneraltaxationratherthansocialinsuranceappearstohavepromotedpolicies that have over the long runbeenmore tightlyfocusedoncostcontrolthanthosejudgedappropriateinothermoreaffluentcountries.TheUKsystemtodayis more centralised and politicised than alternativesocial insurance based health care models in otherpartsofEurope.Thiscouldhaveoffsettheadvantagesassociatedwith the fact that tax funding ischeaper toraise than financing gathered via competing insuranceschemes.

ThissituationmayormaynothavedisadvantagedtheBritishpopulation todate.But from theperspectiveofensuring the futurequalityofprimaryhealthandsocialcareitisimportantforsuchtrendstobewellunderstood.OtherwiseelectoralandgovernmentalchoicesmightbedistortedbyexaggeratedperceptionsofthecostoftheNHSor the supposedgenerosity of the health relatedwelfarebenefitsavailableintheUKasopposedtootherpartsoftheEU.

The impacts of population ageing

In1948therewere5millionBritishpeopleaged65andover, out of a totalUKpopulationof about 50million.Of that 5million, only about 200,000 individualswereaged85or over.Average life expectancyat birthwas68years,and forpeopleaged65 itwasa littleunder14years.Today,bycontrast, thereareover11millionagedover65outofatotalpopulationofsome64million(Figure6).About1.5millionpeople in theUKarenowaged85yearsandover,andthisnumberwillmorethandoubleinthenexttwentyyears.Averagelifeexpectancyatbirthformalesandfemalescombinedisjustover80years.Atage65itisnow21years.

Suchadvancesinsurvivalareinpartattributabletothesuccessof theNHS,and inparticular to reductions ininfectiousandcardiovasculardiseasemortality inchild,‘working age’ and early later adult life. However, it isoften (incorrectly) claimed by political and professionalcommentatorsalikethatpopulationageinghasbeenthemaindriverofincreasedhealthcarecostsandthatitwillinfuturethreatenthefinancialviabilityofhealthservicesascurrentlyconstitutedinthiscountryandelsewhereintheworld.

Itistruethatpopulationageingischangingthebalanceofhospitalandprimaryhealthandsocialcareworkloads–healthcaresystemsneedtoadjusttoaccommodatethisandassociatedtrends(WHO,2015). It isalsotruethatatanygivenpointintimeolderadultsare,outsidethe field of maternity services, likely to require morehealthcarethanyoungerones.Yetitisnotthecasethat,

Figure 5: Cost of Family Health Services (FHS) at 2010/11 prices, UK, 1950/51 - 2010/11

Source:HaweandCockcroft,2013

£million


todateat least,populationageinghasbyitselfbeenamajordriverofincreasedtotalspending.

Thebestavailableevidenceindicatesonlyabout0.2percentofthe3-4percentaverageannualincreaseinNHScostsseeninpastdecadeswasduetothiscauseper se.Infuturedecadestheyearlyextraspendingonhealthcare needed because of the impacts of populationageingmayrisetoabout1percentoftotalNHSoutlays.Yetthiswillnotbeanunmanageableproblem,especiallyifbetterprimarycare ledcasemanagementstrategiesproveabletomitigatethecostimpactsassociatedwithrising absolute (as distinct from age specific) rates oflongtermill-healthandmulti-morbidity.

The future challenges associated with ageing in thiscountry are substantially less than those now facingnations like, for instance, China or Iran, which areenteringintoamuchmorerapidperiodofchangeintheirpopulation structures than that being experienced inWesternEurope.Thebenefitsofincreasedlongevityandhealthy life expectancy achieved in the last century orsosignificantlyoutweighanycoststhatcanreasonablybeattributed toextendedsurvival.This is in largepartbecauseasdeathispostponed,sotooarethecostsofendoflifecareandtovaryingdegreesthoseassociatedwithhavingtolivewithdisability.

If healthy life expectancy canbe extended in linewithoverall life expectancy gains, the net economic costsof such progress could prove negative. However, thisis not to deny that population ageing will over timerequire greater investment in preventive services andeffectivelycoordinatedhealthandsocialcareprovisionin the community. It is once again important from theperspectiveofassuringthefitnessforpurposeofprimary

healthandsocialcarethatsuchphenomenaarewidelyunderstood,andthatappropriateservicedevelopmentsareidentified,fundedandimplemented.

Falling hospital bed numbers

Thenumberofhospitalbedsavailableforthetreatmentofinpatientshasdroppeddramaticallysincethestartofthe1950s.Atthattimetherewereroughly11bedsper1000populationacross theUKasawhole.Today theequivalent figure is about 3 per 1000, andwithin thattotal there are approaching twice the number of bedspercapitaavailableinScotlandasthereareinEngland(HaweandCockcoft,2013).Evensincethelate1970saverageacutebedavailabilityper1000totalpopulationhas fallenbyover40percent inEngland.Thedeclinein mental illness and learning difficulty inpatient bedsavailable has been about twice that figure, and isprojectedtofallfurtherinthecomingdecade.

Such changes have been offset by reduced lengthsofstayandgreateruseofdaysurgery (Figure7),alongwith improved community (including nursing home andresidential)care.Carehomebedsareacriticallyimportantresource, albeit their total number has also fallen sincethe 1990s (Laing, 2015).5 In general the population isbetterhousedandmoreabletocopewiththechallengesofrecoveryorlivingwithmentalorphysicaldisabilitiesathomethanwassowhentheNHScameintobeing.

Even so, it is salient to note that theNHS in Englandhasonlyaboutathirdoftheacutehospitalbedsthanisthecasein,forexample,modernGermany,andthatinsomeareasshortagesofsocialserviceandcommunitynursing resources are significantly delaying hospitaldischarges.Recentdataindicatethatsucheffectsleadtothelossofinexcessofamillionhospital‘beddays’ayearinEnglandalone.Failurestofurtherdevelopprimarycareasdefinedinthisreportwouldinfutureexacerbateproblemsofthistype.

5 Therearecurrentlyaround400,000publicandprivateresidentialandnursinghomebedsintheUK

Figure 7: Average length of hospital stays, England, 1998-2014, and day surgery numbers

Source:HSCIC,2015b

Figure 6: UK resident population and projections by age group, 1951-2051

Projectednationaldata

Note: in 1951 there were 200,000 British citizens aged 85 and over, compared to about 1.5 million today. By 2051 this total will have risen to over 4 million. However, in part because of immigration patterns the UK will by the 2030s have become one of the least aged countries in the EU, and in social and economic terms is likely to be significantly less affected by population ageing than countries such as China


Larger GP practices

Atthestartofthe1950sthereweresome22,000GPsworkingintheUKNHS,outnumberingthethen15,000hospital doctors by a third or more. Many practicedalone,andhomevisitingwascommonplace.

Todaythereareabout40,000GPsintheUKasawhole,over three quarters ofwhomwork in England. This islessthanhalftheequivalentnumberofhospitaldoctorspresentlyemployed.Lessthan10percentofGPsnowworkonasinglepractitionerbasis,andhomevisitingbypatients’ownGPs is relativelyuncommon.Themodalpracticesizehasrisentobetweenfiveandninemedicalmembers. In England practices rather than individualGPsarenowcontractedtotheNHSviaNHSEngland,andtheyhaveintotalsome90,000non-medicalfulltimeequivalent(FTE)staffmembers.

Seventy per cent of the individuals employed as non-medicalpracticestaffundertakeadministrativeandclericalwork.Thenumberofnursesworkingingeneralpracticesremainsrelativelymodest–thereareabout15,000FTEpracticenursesinEngland,whichtranslatestoalittleunder25,000 individuals. In recent years the ratio of practicenursestoGPshasremainedstable.Abouta thirdofallgeneralpracticeconsultationsareundertakenbypracticenurses(Hawe,2009).Theyarenowresponsibleforover100 million patient contacts a year out of the GeneralPracticetotalofapproaching350millionconsultationsayear(Figures8aand8b).Forcomparisonabout1.6millionpeopleadayusecommunitypharmacies,although theannualnumberofhealthrelatedconsultationsundertakeninpharmacieshasbeenestimated tobecloser to450million(NHSEngland,2013).

From a demographic perspective, the proportion offemale GPs has risen during the lifetime of the NHS.So too has the proportion of the GP workforce over50.Over half of all family doctors are now in this agebracket. Presently available data suggest that manyolderGPsare (partly in response tochangingpensionfundregulations,andnewlimitsonthesizeofpensionfundsthatenjoytaxbenefits)contemplatingretirement.This, coupled with uncertainties as to the proportionof youngerwomen doctorswhowill choose to returnto practice after completing their families, has causedsomecommentatorstoexpressfearsthatGPnumberswillsoonfalldramatically.Ithasbeenclaimedthataround5percentofsurgeriesmighthavetocloseby2020.

ButagainstthisthepresentgovernmenthaspromisedtoincreasetheGPworkforceinEnglandby5,000practitionerswithin five years (see next section). The likelihood of asignificantcollapseinNHSGPcareprovisioninEnglandislimited.However,asisdiscussedbelow,therewillalmostcertainlybeanincreasingneedtoemploymorepracticestaffsuchasnurses,clinicalpharmacistsandindividualswithnon-clinicalbackgroundswhohavebeentrainedas

physicianassistantsintheGeneralPracticesetting.ThedevelopmentofcommunitypharmaciesinwaysthatwillrelieveGPworkloadsandmeetNHSuserexpectationsforaccesstoconvenient,safeandotherwisevaluedservicescouldalsoproveaviablewayforward,ifadequateactionistakentosecurethisend.

Community pharmacy roles

There are presently approaching 12,000 communitypharmacies in England, compared with 8,000 GPpractices.The latternumberhasfallen inrecentyears,while the total for pharmacies has risen. There arearound 30,000 community pharmacists employed inEngland,whichrepresentsasimilarnumbertothat forGPs.EnglishCPsaresupportedbyover100,000otherstaff, ranging from registeredpharmacy technicians tocounterassistantswithvaryinglevelsoftraining.

Since the 1950s there has not been an increase inthe number of registered pharmacists working percommunity pharmacy comparable to that seen in

Figure 8a. GP consultations per capita by age group, UK, 1975-2009

Source:OHE

Figure 8b. Total numbers of GP consultations by age group, UK, 1975-2009

Source:OHE


relation to thenumberof doctorsworkingpergeneralpractice.Relativelyfewpharmacieshavemorethanoneregisteredpharmacistondutyatanyonetime.Buttheownership of community pharmacies in England hasbecomemorecorporate.OutsideLondon,over60percent of all community pharmacies are now groupedin chains of five ormore (Figure 9). At the same timetheannualnumberofprescription itemsdispensedbycommunitypharmaciesinEnglandaloneisnowoverabillion.Thiscompareswithabout200millionin1950and500millionatthebeginningofthiscentury.

Anumberoffactorshaveaccountedforthisrise.Theyrange from an extended use of medicines to controlvasculardiseaserisksthroughtotheincreasednumberofolderpeoplelivinginthecommunity.About60percentofallcommunityissuedprescriptionsarenowdispensedforpeopleaged60andover,which inEnglandmeansthattheaverageindividualofthatagereceiveswellover50NHSprescriptionitemsayear.Theequivalentfigureforthepopulationagedunder60yearsisapproaching9itemsperpersonperyear.

Itmightbearguedthattheincreasedworkloadassociatedwiththerecentgrowthindispenseditemnumbers(whichover the lastdecadehasbeen linkedtoa30percentdecline inaveragenet ingredientcostperprescription)will fullyoccupymostcommunitypharmacists.Yet theintroduction of new dispensing technologies coupledwith strategies ranging from themore effective use ofpharmacytechniciansto–inappropriatecircumstances–increasedprescriptiondurations6couldinfutureliberatepharmacisttime.Thisreality,coupledwiththefactthat

6 Thereisevidencethatitisnotalwaysinpatientorpublicintereststoconfinesupplyquantitiesto28daysorlessasopposedto,say,threemonthperiods.

atpresentpharmacy is theonlyhealthprofessionwithasurplusofUKeducatedgraduates,providesevidencethat there is a genuine opportunity for extending theclinical role of NHS community pharmacists, providedservice users find this an attractive option and thatpharmacistandotherstakeholdershavethenecessarymotivationtoextendtheirclinicalcareinputs.

Community nursing

Theumbrella termcommunity nursing covers servicesprovided by personnel ranging from district nursesto community matrons and health visitors. NHScommunity services also employ care assistants, aswellasprofessionalslikephysiotherapists.Intotal,evenincluding nurses employedbyMentalHealth Trusts todeliver community services, only about a fifth of theoverall NHS nursing workforce is located outside thehospital sector. The available data indicate that sincethebeginningof thiscentury therehasbeena50percentdecline in thenumberof individualsemployedasdistrict nurses in England, leaving them at a ‘criticallyendangered’level(HSCIC,2014).

Increasesinthenumberofotherstaffhavetoadegreemitigatedthistrend.Evenso,theRoyalCollegeofNursing(2012)hasexpressedalarmaboutadilutionandlossofskillsinthecommunitynursingworkforceinaperiodinwhichthereisincreasingneedforhighqualitycommunitycare.Thereisevidencethatinsomeareastheworkofcommunity nursing teams has become dominated byinflexible, narrowly task oriented, approaches centredon relatively unskilled activities (Gill and Taylor, 2011).Despiterecentattemptstodevelopmoreintegratedcareand initiatives suchas the establishment of theBetterCareFund,7therearedoubtsaboutthequalityofsocialservicesandcommunitynursingservicecollaborationinmanylocalities.

Thereare likewiseconcernsaboutthe‘dissociation’ofGPandbroadlydefinedcommunitynursingcare.Inlesspro-active practices and localities there are problemsrelatingtothetimelydeliveryofgoodqualitycommunityservicestopeoplelivingwithconditionsthatputthemathighriskofemergencyhospitaladmissions,orbecomingprematurelydependentonresidentialcare.

The historical origins and social status of nursing andalliedcareprovisioninthiscountryarequitedistinctfromthoseofmedicineandpharmacy.Itcanbearguedthatsince the 1974NHS re-organisationwhich transferredthe provision of functions such as district nursingand health visiting away from Local Authority control,this area has lacked the supportive leadership and

7 ThisasfromApril2015hasmadeapproaching£4billionofwhatisinlargepartfundingtransferredfromtheNHSavailableforLocalAuthoritiesandCCGstojointlyspendonsocialandalliedcommunityservices.

Figure 9: Number of community pharmacies owned by independent and multiple contractors* on a PCT pharmaceutical list, England 2006-2013

Source:HSCIC,2014b

* A multiple pharmacy is defined as one consisting of 6 or more pharmacies. Contractors with 5 pharmacies or less are regarded as independent.


institutional sponsorship needed to protect public andpatientinterestsinitsongoingdevelopment.

Individuals interviewed during the development ofthis analysis highlighted funding and financial rewardissues,andthenegativeimpactsthatcreatingseparatecommunity matron posts may have had in termsof depriving district nursing teams of appropriateprofessional leadership. A core reason why it hasbeen difficult to retain professional staff in communitynursingservicesisthatmanyhavenotbeenofferedanenvironment in which they feel it is attractive to workand possible to deliver high quality professional care.AtthesametimeaccesstoLocalAuthoritysocialcarehas decreased. Some commentators believe that theLAcommissioningapproachesusedhaveonoccasions‘auctioned down’ the quality of social and communitynursingservicestounacceptablypoorlevels.

TheproblemsfacingNHScommunityserviceprovidershavenowinpartbeenacknowledgedbyagenciessuchasNHSEngland.ItrecentlycommissionedtheQueen’sNursing Institute todevelopa resource tohelpensurethat localities have sufficient numbers of communitynurses inplace. There is a commitment to training anadditional10,000‘frontline’communitynursingstaffby2020, and the Primary Care Workforce Commission(2015) concluded that all localities should as amatterofpriorityseektohaveanadequate24hourcommunitynursingserviceinplace.

Such developments are encouraging.But they shouldnot conceal the systemic failure of the NHS in recentdecades to develop community nursing and alliedservicesthatarebettersuitedtomeetingtheneedsofa ‘post-transitional’population.Theapproachadoptedin England may be seen as comparing poorly withexamplessuchasthatsetby,forinstance,theBuurtzorgcommunity careprogramme in theNetherlands (RCN,2015).

Thislastinitiativeoffersanillustrationof‘self-managed’organisation.Although its viability in themore unequaland class divided British cultural environment has notbeen demonstrated, the Buurtzorg model (along withrelatedSwedishstrategies)providesasetting inwhichperson-centred care can be delivered in ways whichenablenursingandothernon-medicalstaffahighlevelofself-realisationandprofessionalreward.Itisthereforean important experiment for practitioners interested inrealising thepromiseofconceptssuchas theNAPC’s‘PrimaryCareHome’ toexplore. It ispossible that thethinking it embodies could be applied in ways whichwillinfutureallowbettercollaborativeworkingbetweenGPs,pharmacists,communitynursesandotherprimaryhealth care colleagues in order to generate increasedserviceusersatisfactionandenhancedcareoutcomes.

Current OpportunitiesThe extent to which NHS primary care can currentlybesaid tobewellmanaged inEngland isdebateable.The decades between the end of the 1940s and thepresentdaysawwhatmightbetermeda‘slow-motionmanagerial revolution’ in the organisation of hospitalcare,notonlyintheUKbutalsoinmuchofEuropeandin the United States. Yet in the case of primary care,‘postGriffiths’generalmanagementhasnotinthemainbeen developed, and where it has been instituted itsachievementshavebeenofquestionabledesirability.

The recent establishment of Clinical CommissioningGroups,coupledwiththeformationofthelocalGeneralPracticeFederations thathavebeenadvocatedby theRoyalCollegeofGeneralPractitionersforapproachingadecade(Lakhanietal,2007),offersimprovements.Butdespite recent steps likeextending thepartplayedbyCCGsinthedevelopmentofprimarycare,thishopeisaccompaniedbycontinuinguncertainties.Althoughthepost GP Fund-holding ‘commissioning experiment’ intheNHSmayhavebeenwell intentioned,manyof theprofessional and other leaders interviewed during thepreparationofthisreportsaidthatithasnotbeenabletoadequatelyfacilitatetheestablishmentandcoordinatedlocaldeliveryofservicesneededbycommunitiesinthelatestagesofdemographic,epidemiologicalandsocialtransition. In areas like Community Pharmacy positivechangehasalso–althoughcumulative–beenrelativelyslow,while theprovisionofskilleddistrictnursingcarehasuntilrecentlyatleastbeenindecline.

As previously recorded, in the 1960s the AmericansociologistEliotFreidsonarticulatedconcernsrelatingtothedominanceof themedicalprofession in thehealthsphere, and what he judged to be a self-interestedemphasis on ‘clinical freedom’ as opposed to theappropriate provision of public and patient interestfocusedcare.YettowardstheendofhiscareerFreidsonhad become worried about the unwanted impacts ofhealth sector managerialism and regulatory systemsthat he increasingly saw as heralding destructivebureaucratisation. He feared that such trends wereleading to controls that threaten patient interests bypromotingunduerigidityandunderminingthequalityofdiscretionary decision making in day-to-day treatmentandcare.EliotFreidsonineffectarguedthatprofessionalvaluesareneededasacounterbalancetoprotectservicequality against inadequately informed managerialismand/orpoliticalinterventionism(Freidson,2001).

TheNHStodaydiffersconsiderablyfromthehealthcaresystem that existed in late twentieth century America.However, if in future NHS primary care is to be ableto helpmeet public expectations for both the efficientand effective use of hospital resources aswell as theprovision of high standard community services, there


willbeacontinuingrequirement tocomplementskilledmanagerialdirectionwith‘modern’professionalismandenhancedresponsivenesstothepreferencesofserviceusersatallstagesoftheirlives.

During the prelude to the May 2015 general electionNHS England’s Five Year Forward View highlighted anumberofwaysinwhichprimarycareandalliedserviceimprovements might help generate the gains neededforthehealthservicetostaywithinbudgetandperformwell in the period to 2020. The advances suggestedrangedfromthecreationofurgentcarenetworkstohelpmanagedemandforemergencytreatmentsthroughtothe (re)establishmentof ‘viable’ localhospitalsand theformationofMultispecialtyCommunityProviders(MCPs)and/or integrated Primary and Acute Care Systems(PACS).

These and other what are now termed ‘Vanguard’initiatives link back to earlier experimental schemestrialledinEngland,includingthesixteenIntegratedCarePilots (ICPs)established in thewakeof the2008NHS Next Stage Review.MCPscantoadegreebecomparedto the polyclinic concept previously advocated bycommentatorssuchasLordDarzi.Theycouldalsobedeveloped inways that reflect the recent formation ofAccountable Care Organisations in the United States.ACOs are groups of service providers that typicallyinclude primary care practitioners, nursing homes andhospitals, and that take responsibility for meeting alltherelevantneedsofagivenpopulationforaspecifiedperiodof timeandwithinadefinedbudget (Shortelletal,2014).

ThereareavarietyofwaysinwhichNHSprimarycarecoulddevelopoverthecomingdecade(Rosen,2015).Of these it currently appears that defined budgetinitiativesdesignedtomeetregisteredpopulationneedsoverspecifictimeperiodsarethemostpromising.TherecanbenoguaranteethatformingACOtypesystemswillenabletheNHStoovercomethechallengesnowfacingit inEnglandandotherpartsof theUK.However, theNationalAssociationforPrimaryCare(2015)hasarguedthat‘PrimaryCareHome’basedmodelsthatreflecttheACOapproachdeservecloseattention.

Such organisations might in future be formed bybuildingon theemergenceofGPFederations,andbedesignedtoservepopulationsof30-50,000orperhapsmorepeople.8Theycouldofferbenefitssimilartothoseattributedtothe‘multi-funds’thatintheUKformedinthelaterstagesofGPFund-holding.EstablishingMCPsinamanner consistentwith theNAPC’s recommendationsdoesnot requirestructuralmergerswhichdissolve theunique identities of smaller participant organisations.

8 Giventhevariabilityoflocalcommunitycarerequirementsanddifferingservicedevelopmentopportunitiesbetweenlocalities,attemptingtoimposeundulyrigidservicedevelopmentspecificationswouldriskbeingcounter-productive.

Apartfromthemotivationaladvantagesthismightbring,it could also permit the ongoing flexibility needed fornewconfigurationstoformwithaminimumofdisruptiveimpactonserviceprovisions,asandwhenthiswouldbedesirable.

The formation of Primary and Acute Care Systems(PACS)alsorelatestotheACOmodel,theestablishmentofwhich inAmericawasstimulatedbythepassageofPresident Obama’s 2010 Affordable Healthcare Act.However,PACSarearguablymorelikelytoinvolveformalmergersofhospitalandprimarycareservices.Someofthose interviewedduring thepreparationof this reportsuggestedthatthiswouldbearobustandsustainableway forward, given the organisational strength anddurabilityof largehospitals.Othersarguedagainst thisoption,inpartbecauseoffearsthat‘hospitaltake-overs’coulddamageprimarycareanddistortoverallpatternsof service use.9 They expressed the view that publicinterestswillbestbeservedbymaintainingaclearfocusonthedistinctprinciplesforexcellence inprimarycaredelivery established by researchers such as Starfield,and building logically on the discrete strengths of thiscountry’sestablishedprimarycaresystem.

The NHS structure and ‘single payer’ fundingsystem has some advantages as comparedwith thealternative arrangements typically in place in otherdeveloped countries (Davis et al, 2014). There is noreason to doubt that it could, given sufficient will,be further strengthened without counter-productivereorganisations. The importance of the NationalAssociationforPrimaryCare’srecent‘7pointplan’anditsworkondevelopingthePrimaryCareHomeconceptofapracticepopulationbasedapproachtoeffectivelycoordinatingpersonalisedhealthandsocial care is inpart linked to the fact that it reflects a commitmentto patient care centred values, coupledwith the useof appropriately designed performance and outcomemetrics. Some important elements of the NAPC’sproposalsarehighlightedinBox4.

Forming larger organisations is sometimes seen asameansof integrating complex activities.But there isno evidence that simply bringing different health andsocial services together under a single management‘umbrella’ would (as with the co-location of GPs andspecialist doctors in shared premises) in itself createthe relationships, values, commitment and expertiseneeded to sustain long term solutions to the multi-faceted problems of optimising health and social carecoordination.

9 Incircumstanceswherehospitalsarenotcompetingformarketshareagainstrivalproviderssuchrisksmaybesignificantlyreduced.Evenso,theviewtakenhereisthataprimaryratherthansecondarycareledapproachislikelytoenjoysignificantadvantagesfromapublicinterestperspective.


Thehistoryofcommunitynursingafter1974calls intoserious doubt the wisdom of transferring the controlof community service funding to bodies that have adominant interest in institutional care provision. ThefactthatcountrieslikeSwedenhavemaintainedaclearseparation between health and social care in order toprotect funding levels and maintain discrete serviceobjectivescanalsobetakentobeindicativeoftheneedfor caution with regard to adopting care integrationstrategies based on the imposition of organisationalandbudgetaryunity,asdistinctfrompreserving‘natural’pluralitywhileincentivisingfunctionalcollaboration.

The nextmain section of this report further discusseshowbarriersrelatingtotheprovisionofbetterorganised,individually responsiveyetefficientatscale,healthandsocialcaremightbestbeovercome.ButbeforethattwoareascentraltotheimmediatefutureoftheNHSprimarycarearefurtherconsidered.Thefirstrelatestohowtheparts played by non-medical staff working in GeneralPractice should be extended. The second furtheraddresses how independently located communitypharmaciesandthepeopleemployedinthemwillbestbeabletocontributetotwentyfirstcenturyprimarycare,alongsideotherserviceproviders.

Thefactthattherearenownewopportunitiesforclinicalpharmacists to work in General Practice settings is awelcomedevelopment.But this shouldnotundermineawareness of the continuing need for communitypharmaciestosupplymedicinesandalliedproducts inconvenientandcost-effectiveways,orofopportunities

for them–asandwhenserviceuserselect toaccesspharmacies for health care delivery – to extend theircontributionstofacilitatingself-careandprovidingdirectaccesstopharmaceuticalandalliedtreatmentsinwaysconsistent with the cost-effective attainment of goodqualitycarestandards.

General Practice teams

When individuals are facing serious health problemsmany wish to be guided by GPs who they not onlyknowtobequalifiedprofessionalsbutare familiarwithaspeoplewhoareapartofthesocialnetwork/humancapitalthattheyandtheirlocalcommunities‘own’,andare hence highly trusted. Arguably, the fundamentaltest for General Practice in the period to 2050 is toretain its heritageof being a local resource for patientpopulations while also being a major influence onclinicalcommissioning. Ideally, itneedstobe ‘small’ inpersonal relationship terms, yet ‘large’ in the senseofbeingabletoactasanimportantsystem-levelNHScarecommissionerandprovider.

Therecentlyannounced‘NewDealforGeneralPractice’–seeBox5–recognisesthecentralityofGPcareintheNHS,andpromisestoincreaseGPnumbersinEnglandby5,000by2020. Italsooffersto increasetherestofthe General Practice workforce by a similar number,including a commitment to making 1,000 PhysicianAssociatesavailable ingeneralpracticesbytheendofthecurrentdecade.

Box 4. Improving Primary Care

The National Association of Primary Care’s 7 PointPlan (whichwasfirstpublishedin2014)canberegardedas an attempt to apply evidence based principles ofquality management to the delivery of person andpatientcentredpopulation-widehealthandsocialcare.Itskeyprioritiesrelateto:

•defining the value of care around outcomes thatmattermosttopatients/serviceusers;

•supportingnewmodelsofprimarycareprovisionthatshould help to ensure that service users’ personalrequirementsaremeteffectivelyandefficiently;

•aligning incentives and contractual models thatsupport improvements in local population healthoutcomes;

•developing a workforce that is responsive to theneeds of the populations being served, rather thanfocusedonmeetingthoseoftheprofessionalgroupswithinit;

•supporting‘realtime’innovationacrosscollaborativenetworks, inpart through the ITbaseduseofwell-

designed activity and performancemetrics in waysthatareseenasimportantbyallthosetakingpart;

•purposeful,notjustpositional,leadershiprepresentingthebreadthofprimarycare;and

•working to influencepolicies inways thateffectivelysupporttherealisationoftheambitionssummarisedabove.

The thinking underpinning the NAPC’s Primary CareHomeconceptandthatofthe50Vanguardcaremodelimplementation projects now (as ofDecember 2015)beingsupportedbyNHSEnglandcansimilarlybeseenas seeking to apply the principles of service qualitymanagement to the task of continuously improvinghealthandsocialcare.Encouragingprogresshasbeenreported.However,aswith themultiplepilotprojectsthat across theworld have repeatedly demonstratedthe capacity of clinical pharmacy in both integratedandindependentlysitedcommunitysettingstodelivergood quality health care, core challenges relate touniversalising good practices in ways that defendthe local integrity of professional work and stimulateautonomousimprovementpractices.


TheseplansinpartstemfromtheworkofanindependentPrimary Care Workforce Commission which formallypublished its report in the summer of 2015 (PCWC,2015).The Future of Primary Carenotedthatalthoughthe number of hospital consultants increased by 48per cent in the decade 2003-13, the number of GPsincreasedbyonly14percent.SuchdatamaybetakentobeevidenceofaskewedandinadequatelymanagedpatternofworkforceinvestmentduringthedecadeorsoofrapidNHSfundinggrowththatendedshortlyafterthetimethatthe2008globalfinancialcrisiscommenced.

Duringthefirst10-15yearsofthiscenturyprimaryhealthand social care provision did not keep pace with therapid expansion of complex specialist hospital activity,andtheparalleldeclineinhospitalbednumbersavailableinEngland.Thisledtoanaccumulationofrisks.Failurestoadequatelyanticipateandforestallthissituationcan–notwithstandingmeasuressuchastheintroductionofarevisednationalcontractin2004thatrightlyorwronglyremoved GP responsibility for providing night andweekendcare–be takenasan illustrationofnotonlyprofessional leadership limitations, but also significant

weaknesses in NHS governance and direction at itshigherlevels.

Inlinewiththeinformationreportedearlierinthisreview,theCommissionalsoobservedthattherewasa38percentdropinthenumberofcommunitynursesinthetenyears2001-2011.Only inpharmacy are there enoughnew professionals being trained in theUK tomeet orexceed anticipated future demands for health sectorstaff. In the institutional setting in particular, nursingcareinBritainhasinrecentdecadesbeensubstantiallydependentonprofessionalswhohavequalifiedinpoorercountries.Recentlyannouncedchanges in the fundingofnursingeducationmaynothelpchangethissituation.

There have also been consistent shortfalls in thenumbers of doctors trained in this country. This mayin part have been related to attempts tomaintain thestatus and relative earnings ofmedical staff trained intheUK,alongwithfearsthatBritishgraduateswillifthereare not adequately attractive opportunities availabledomestically swiftly seek employment elsewhere inthe English speakingworld. Butwhatever the reason,manyoftheNHS’scurrentfinancialandservicedelivery

Box 5. ‘New Deals’ for General Practice and Community Pharmacy?

In 2014 NHS England’s pre-election FYFV calledfor better funding and support for general medicalpractice,inordertofurtherimprovetheNHS’soverallperformancethroughenhancedprimaryandsecondarydiseasepreventionandbetterpopulation-wideaccessto well-coordinated primary/community medical,nursing and pharmaceutical care. In June 2015 theSecretaryofStateforHealthofferedhisvisionofa‘newdeal’forGPstohelpachievesuchgoalsinEngland.

Drawinginpartontheworkofthe‘RolandCommission’– seemain text – the plan outlined by JeremyHuntincludedearmarking£10million forgeneralpracticesin need of special support and the recruitment of5,000 newGPs and another 5,000 practice supportstaff (including practice nurses, district nurses,physicians’ associates and practice based primarycarepharmacists)bytheendofthecurrentParliament.Italsobuiltonacommitment toprovide£550millionfor themodernisationofGPsurgeriesand improvingcommunity based care announced in March 2015,and heralded contractual changes that should offergreater working freedoms for practices in returnfrom the introduction of extended ’7 day’ NHS carearrangements.

Subsequently, it was also announced that everyoneinEnglandwillhaveaGPwhoisrecognisedasbeingpersonallyaccountable forcoordinating theirphysicalandmentalhealthcareneeds.TheSecretaryofStateinadditionnotedtheimportanceofgeneralpracticeinthewiderpublichealthcontext,andthefactthatabout20 percent of the average GP practice’s workloadis associated with supporting people affected by

problemssuchassocial isolation,housingdifficulties,personal relationship issues and the consequencesof unemployment. He emphasised the need forrobust linkagesbetweengeneral practice and social,communityandmentalhealthcare.

This package of initiatives has been generallywelcomed, although warnings have been soundedwithregardtoissuessuchastheextenttowhichthefinancialincentivisationofspecificprofessionalpracticeimprovements could have perverse consequences inotherimportantareasofworkthatdonotreceivespecialfunding.Fromtheperspectiveofthisreportitmayalsobesuggestedthatmoreattentionmightusefullybepaidtotheestablishmentofaparallel,effectivelyintegrated,‘newdeal’forcommunitypharmacistsworkingoutsidethegeneralmedicalpracticesetting.

RecentcallsbytheTreasurytoincreasetheuseofonlinepharmacy and home delivery services (Cmnd 9164,2015)appeartobesupportiveofdrugdistributioncostsavingstrategiesthatmight intime leadtosignificantreductionsinthenumbersofindependentand/orchainpharmacies across the UK. However – as initiativessuchasthedevelopmentofHealthyLivingPharmaciesmay be taken to indicate – it could well provecounter-productive to ignore the actual andpotentialcontributions of pharmacies to clinical care deliveryandwider public health improvement, especially if infuture the ‘public health’/population level preventiveuse ofmedicines outside the conventional sphere ofdiseasetreatmentindoctors’surgeriesbecomes–asisdiscussedinBox7below–morewidelyaccepted.


problems can be linked to an inadequate supply ofsuitablyskilledstaff.

ThePrimaryCareWorkforceCommissionrecommendedthat GPs should retain their central responsibility forprimarymedicalcarequalityandthedeliveryofpersoncentred support. It also argued that the balance ofGeneralPracticeactivitiesshouldovertimemovemoretowards incorporatingpopulationbased ‘publichealth’approaches in relation to the management of healthrelatedrisks.Greaternumbersofnon-medicalpracticestaff could help to make the adoption of ‘communityorientedprimarycare’strategies(seeGeiger,1993)andpracticespossible.

Forexample,The Future of Primary Careclaimedthatifmedicalassistantsweretoundertake50percentoftheadministrativeworkcurrentlydonebyGPs, thiswouldreleasetheequivalentof1400doctorsforclinicalworkinEngland.Physicianassociates(graduateswithrelativelybrieftraininginkeyhealthcareareas)couldalsotakeonmoreprimary care tasks, as too –dependingon theiravailability–couldnursepractitionersandpharmacistsworking in practice settings. Shortly before thepublication of the Commission’s report, NHS Englandannouncedpilotfundingfor‘practicepharmacy’posts.

So far funds sufficient for the support of about 400such appointments have been announced. EmployingpharmacistsinGPsurgeriescanbetakenasrecognitionoftheirvalue,andmighthelpprovideapartialsolutiontolimitationsinthenumberofdoctorsseekingcareersasGPs.Yetthelongtermeconomicsustainabilityofsuchawayforwardisasyetuncertain.Therewillbesignificantcosts to be met in successfully establishing a moreteam based model of primary medical care delivery.But its advantages should include allowing longer GPconsultation times for patientswith relatively extensiveneeds.OtherCommissionrecommendationsrelatedto:

• encouraging greater use of emails and (securitypermitting)webbasedcommunicationsinbothintra-professionalandpractitioner/patientinteractions;

• creatingsinglepointsofaccessforcommunityhealthandsocialcareneedsassessments;

• improving career structures for nurses and othersworkinginprimaryhealthcare;

• funding24hour7daycommunitynursingservicestofacilitatetimelyhospitaldischarges;

• ensuringthatthereisequitablegeographicalaccesstogoodqualityGeneralPractice;and

• developing local Federations that involve both GPsandcommunitypharmacists.

Theextenttowhichsuchaspirationscanbetranslatedintoactualserviceimprovementswillinlargepartdepend

on the financial and allied incentives influencing thebehavioursofindividualsandorganisations.Constructivechange in General Practice and other primary careservices will be possible if it is pursued in a realisticmanneranddevelopment investment issustainedoversufficientperiodsoftime.

However, if the performance of NHS primary care indelivering not only continuing personal support forindividualslivingwithcomplexneedsbutalsointerventionsforpeoplewho requirequickandeasyserviceaccessis tobeoptimised, improvingpracticebasedcareco-ordinationisnottheonlygoal.Despitesomeoutstandingexamplesofcomprehensiveprovision,itishighlyunlikelythat largerGeneralPracticeswillbeable tomeetboththegrowingneedforcontinuingmedicalcareformoreseriouslyillindividualsandparalleldemandsfortherapidand convenient delivery of preventive and day-to-dayself-caresupportand‘maintenance’servicesforchildrenandadults.Additionalwaysofofferingsafe,timelyandconvenienttreatment,supportandadvicearealsolikelytoberequired.

Clinical pharmacy in the community

Before the establishment of the NHS, communitypharmacists in Britain played an important part inproviding health care as well as in dispensing thecomparatively limited (often pharmacymade) range ofeffectivemedicines then available. But the creation ofthehealthservicecoincidedwiththefirstpharmaceuticalrevolution. This generated awave of drug innovationsthat started with the introduction of new, industriallymanufactured and packaged, antibiotics like thepenicillinsandthetetracyclines,coupledwithproductslike isoniazid for the treatment of tuberculosis. Suchdevelopmentswere followed later in the1950sby themarketingofproductssuchastheearlyanti-depressants,diureticsforthecontrolofbloodpressure,poliovaccinesandthefirstoralcontraceptives.

CombinedwithNHSfundedaccesstomedicallyprescribeditems (prescription only medication was also a relativelynovelconceptatthattime),pharmaceuticalprogressgreatlyincreasedtheCommunityPharmacydispensingworkload.Pharmacists became less engaged with treating healthproblemsdirectly,andmorenarrowlyfocusedonmedicinesupply(TaylorandCarter,2002;Anderson,2007).

Today, General Practices are larger and more difficulttoaccessthaninthepastandare,asalreadyoutlined,having to dealwith patient and population needs thatdiffermarkedly from the infection related requirementsthat were more prevalent when the NHS was firstestablished. At the same time new technologies andbetteruseofskilledpharmacytechniciansarepromisingwaysoffreeingpharmacistsfromatleastsomeaspectsof the medicines supply and dispensing task, and of


improvingcommunicationand recordsharingbetweenallNHSserviceprovidersandusers.

In England, changes ranging from the introduction ofmoreGSLandP(freesaleandpharmacyonly)medicinesto the funding of ‘minor’ ailment treatment initiatives,smokingcessationservicesandother localschemes–alongsidethenationalfundingofMedicineUseReviews(MURs)and,morerecently,theNewMedicinesService(NMS)–canbeseenaspreparingcommunitypharmacyforthedeliveryofanextendedprimaryhealthcarerole.The same may be said of initiatives such as repeatdispensingschemes,theestablishmentof‘HealthyLivingPharmacies’,andthedifferentbutrelatedapproachestodevelopingcommunitypharmacybeing introducednotonlyinUKcountrieslikeScotlandbutinnationalsettingslikethoseofAustralia,CanadaandtheUS(Box6).

In recent decades there has been an increasedunderstanding of issues such as how communitypharmacy’s traditional ‘volumesupply’basedbusinessmodel and in the UK the matching structure of NHSpharmacycontractshastendedtocurbtheprofession’sability to move from dispensing towards clinical care,and provide services that require time to be spent onestablishing flexible dialogues with service users in

order toprovideeffectivesolutionstohealthproblems.Yet there is also growing evidence on the capacity ofpharmacybasedservicestodeliverbetteroutcomesinareassuchasthesupportofpeoplewithconditionslikeCOPD,asthma,chronicpainordiabetes.

Nationallyandinternationally,researchfindingsfrompilotschemes indicate that Community Pharmacists couldplay more important roles in areas ranging from thedetectionofmentalhealthproblemstothemanagementof long term physical conditions and the reductionof vascular disease risks like raised blood pressurein middle and later life (Box 7). However, despite aplethoraofexamplesofsuccessfulsmallscaleinitiatives,pharmacists have across theworld facedproblems inestablishing‘scaledup’healthcareroles.Findingwaystoaugmentandovertimereplace‘itemofservice’baseddispensing income streams with a sustainable healthcarerevenuebaseliesattheheartofthischallenge.

The view taken here is that independently locatedpharmaciesandpharmacistscouldandshouldinfutureplayamorecentralpartinprovidingeasierfirstandwhenappropriatesubsequentaccesstoclinicalcare,providedthatinfutureallprimarycareinterventionsare–withdueserviceuserpermission–enteredintoacommonhealth

Box 6. National and Global Pharmacy Developments

Throughout Western Europe and North Americamanyexamplesareavailableofcommunitypharmacybasedinitiativesthatpromisebetterhealthoutcomes.Wellresearchedillustrationsofthelatterexistinareasranging from the prevention and treatment of type 2diabetesanditsprecursorstatesthroughtodisorderssuchas,forinstance,osteoporosis(Tayloretal,2015).Incountries likeCanada therehasalsobeengeneralprogress towards pharmacist prescribing in not onlyemergencysituationsbut in themanagementof longtermconditions.Thebestknowninstanceofthisrelatestotheprovisionsforindependentpharmacisttreatmentinstituted in Alberta, although related advances havealsobeenachievedinotherProvinces.

In the UK relevant pharmacy development examplesincludetheintroductionofNHSfundedMedicinesUseReviewsinEnglandin2005,theestablishmentoftheScottishChronicMedicationService in2010and theformation of the English New Medicines Service in2013. The latter seeks to support medicines takingintheespeciallyvulnerableperiodaftertreatmentsforlongtermusehavefirstbeenprescribed. Inaddition,local initiatives such as the Community PharmacyFuture(CPF)project–acollaborationbetweenBootsUK,TheCo-operativePharmacy,LloydsPharmacyandRowlandsPharmacy – have highlighted the potentialvalueofextendedpharmaceuticalcare.

TheresultsoftheCPFindicatedthatsome£400millionayearcouldaccruetotheNHSinEnglandfromwork

injustonefield,thatoftheearlydetectionofChronicObstructive Pulmonary Disease and the appropriatecareandsupportofindividualsandfamiliesaffectedbyCOPD.Other examples of innovative pharmaceuticalcare provision range from the encouragement of‘pharmacy first’ approaches to seeking care forcommon conditions in Yorkshire through to greaterpharmacist involvement in clinical research and thetreatmentofskinconditionsinCornwall(Turner,2015;Bearman,2015).

As general medical practices grow larger and morecomplex, the NHS and pharmacists working in itwill (along with other health professionals) haveincreasing opportunities for systematically extendingtheclinicalandalliedpreventivesupportofferedtothepublic in easily accessible premises, provided thesecan be satisfactorily linked via robust IT systems toGP practices and other primary care facilities. Thisapproach,whichmaytoadegreebetakentomirrortheprimaryandsecondaryhealthcentremodelenvisagedbyLordDawsonalmostacenturyago,mightwell intime generate major economies in ways genuinelyconsistent with better service quality and outcomes.However,immediatepressuresforcostsavingsinthenarrowerfieldofdrugdistributionmayimpairthe‘reach’ofthecurrentcommunitypharmacynetworkbeforeitsnewutilitiescanemerge,unless relatively rapidstepsare taken towards realising community pharmacy’sextendedpromise.


record.Theestablishmentof the latter in theNHSwillopenthewaytoindependentlysitedpharmacyservicesbeingabletoimproveaccesstoavarietyofdiagnosticandtherapeuticserviceswithouttheintegrityofmedicalandwiderhealthrecordsbeingundermined.

ThisisnottodenythevalueofGPsbeingabletobuildupcontinuingrelationshipswithpatientsinwayswhichwill help them to identify atypical states and seriousillnessesasandwhentheyoccur.Butitistoacceptthatmany interventions– like, for instance, vaccinationsorprescribingmedicines for ‘firstcontact’ andpreventivepurposes and for treating common (as distinct fromminor) chronic illnesses – could often be convenientlydeliveredinpharmaciesaswellas,whenserviceuserspreferit,ingeneralpractices.

Not all health policy analysts accept the case forextending the clinical role of community pharmacists.Theyargue instead that itwouldbebetter for themtofocusonminimisingdrugsupply costsandoptimisingthe prescribing and use of medicines. For instance,Mossialos et al (2013) warned that (internationally)attempts to change the role of CPs could causedisruptive pressures elsewhere in primary health careeconomies. They suggested that there is to dateinadequateevidencethatcommunitypharmacistshavethecompetenciesneededtodeliverclinicalcaretothestandards achievedby nurses anddoctors in hospitalclinicsorbyGPsandtheirpracticeteammembers.

The HOMER trial of home based medication review(Hollandetal,2005)isasourceofevidencesometimesquoted in support of such views. It found that homevisits topatientsbypharmacistsundertakenafter theyhadbeendischarged fromhospitalcare inEastAngliain order to help improve medicines taking had theparadoxical effect of increasing hospital re-admissionrates,withoutenhancingsurvival ratesorqualityof liferelated outcomes. This research also generated dataindicating that the didactic approach taken by thepharmacistsinvolvedinthisprojectunderminedpatients’confidenceintheirmedicinestakingabilities,andhencewas likely to have impaired rather than improved theirdrugusage(Bienkowska-Gibbsetal,2015).

However,itisimportantnottoover-statethesignificanceof such studies. With regard to the HOMER trial, forinstance, the research conducted did not involvecommunityorprimarycarepharmacistswithestablishedrelationships with local GPs and the patients beingtreated(Smith,2015).Individualsworkinginprimarycaresituations with which they are not adequately familiarandforwhichtheyhavenotbeenfullytrainedcannotbeexpectedtogeneratethesameoutcomesasthosewhohaveestablishedrobustcontextualrelationshipsandarebetterawareofboththeproblemstobeavoidedandtheopportunitiestobetaken.

With regard to the conclusions reached byMossialosandhiscolleagues,theymaynotapplyinthecontextof

Box 7. Reducing the Age Specific Incidence of Vascular Disease and Dementias through new models of Pharmaceutical Care

In December 2015 the President of the Academy ofMedicalSciences,ProfessorSirRobertLechler,calledformoreattentiontobepaidtotheopportunitiesfornewandestablishedmedicinestobeusedasinstrumentsfor prevention and public health improvement, asopposedtotheirtraditionalapplicationsascurativeorsymptom relieving agents (Brimelow, 2015). To datethemostwidelypublicisedexampleofsuchastrategyrelates to theproposeduseofstatins incombinationwith low dose anti-hypertensives for the primaryprevention/delayofeventssuchasstrokesandheartattacks(Wald,2015).

Such thinking has to date proved controversial, notonlybecauseofapparentconcernsaboutdrugsafetyand the relative desirability of promoting healthy lifestyles rather than medicines use, but also becauseof its potential impacts on GP practice workloads.It may be argued that if doctors spend too muchtime on preventive activities of any type, access tomedical care in the event of frank disease could beundesirably reduced. Some commentators mightalso – even if immediate safety issueswere resolvedbeyondreasonabledoubt–beopposedtopermittingalternative health care providers to facilitate publicaccess to medicines such as combination products

fortheprimarypreventionofvasculardisease.This isbecause of thewider impacts thismay have on themedicalcontrolofaccessto,andthepublic’suseof,medicinaldrugsasawhole.

Beyondvasculardiseaseprevention, therearealreadyother areas in which non-conventionally suppliedpharmaceutical interventionsarehavingorcouldhaveimportant ‘public health’ impacts. They range fromsmoking cessation support and the control of dentalcaries to the prevention of HIV transmission and –potentiallyatleast–theoccurrenceofosteoporoticspinaldisorders and some cancers. As bio-pharmaceuticalinnovation continues and humanity’s knowledge offundamental disease causes and developmentalpathways expands, many additional opportunities forsuchpreventiveinterventionswillemerge.

Inthecomingtentotwentyyearsthisis,forexample,likely to be so in relation toAlzheimer’sDisease andother forms of dementia. Figure 2 (page 3) of thisreportsuggeststhatinfuturecommunitypharmacistsmightbeablecosteffectivelytoplayanextendedroleinhelpinghealthypeople tochoosepharmaceuticallybasedpreventivecare,aswellasinareaslikeenhancingaccesstogeneticandotherrisktestingandpromotinghealthprotectivelifestyles.


nationslikeEnglandwhereprimarycarefacessignificantshortfallsinmedicalstaffavailability.ThroughouttheUKsignificant effort has already been put into preparingfor substantive extensions in the role of pharmacists.QualitativeinterviewsundertakentoinformthisanalysissuggestedadegreeofmedicalaswellaspublicsupportfortheconceptofprovidingclinicalpharmaceuticalcareinnotonlyhospitalclinicsandGPpractices,butalsointheindependentcommunitypharmacysetting.

Thisisnottodenytheneedforappropriatecompetencyassessments and Community Pharmacy staffing andgovernancestandards,orthatonoccasionspharmaciststhemselves may be reluctant to adapt their ways ofworking to meet new patterns of need and serviceaffordability.But if innovationssuchasthe introductionofgraduate‘physicianassistants’aretobe introducedinGeneralPracticeitwouldseemperversetorejectthefurtherextensionofappropriatelystructuredhealthcaredelivery roles in regulatedpharmacysettings.Likewiseif the furtherdevelopmentofnursepractitioner roles incommunitysettingsistobewelcomed,thesamemightbetakentoapplytopharmaceuticalcareextensionsinnotonlygeneralpracticebutalsoinindependentlysitedpharmacies.

Innovationcannotnormallybeachievedwithout takingmanagedrisks.Waitingfordefinitiveevidenceofsafetyandeffectivenesstoemergebeforeadoptingnewserviceconceptscanbearecipeforstasis.ThetransformativeideaoftheNHSitselfwouldalmostcertainlyhavebeenstillborn,hadnotthenational leadersofthedaybeendeterminedtoproceedonthebasisof logicandgoodwillata timewhen thecountrywas recovering fromaperiodofextremedangerandgreatfinancialloss.Today,bycontrast,Britishsocietyismoresecureandinsomerespectsmoreriskaversethanithaseverbeenbefore.However, if primary care in general and CommunityPharmacyinparticulararetomoveforwardinwaysthatoffersignificantimprovementsforserviceusers,decisivepolicychoicesareultimatelygoingtohavetobemade.

Achieving Faster Access to Better CareFigure10outlinesapossiblefuturemodelforNHSprimary/communityhealthandsocialcare.Asingle‘onesizewillfitall’approachcannotbeappliedineveryurbanandruralareaofacountryasdiverseasEngland is today.Thereisnoone‘magicbullet’solutioncapableofguaranteeinganswerstoallthecarecostandqualitychallengesfacingthe NHS. But it is realistic to seek a broad frameworkwithinwhich‘pro-activeGeneralPracticeandCommunityPharmacy’couldmoreeffectivelyworkwithcareproviderssuchascommunitynurses,social serviceprofessionalsand specialist physicians to deliver better support topeoplelivingwithconditionsthat,withoutgoodcare,are

likelytoresultinapoorqualityofdailylifepunctuatedbyrecurrentinpatientadmissions.

The unique success of general practice throughouttheUKisbasedoncontinuityofpersonalcaredeliverycoupledwiththecapacitytounderstandandmeettheneedsof registeredpracticepopulations.Yet althoughGPsplayavitalpartinprimarycare,aconstructivevisionforthefutureshouldnotover-emphasisetheircentrality,or deny the importance of forming good relationshipsbetween all actors in the NHS (Colin-Thomé, 2011).Well-coordinatedandclinicallyempoweredCommunityPharmacyservicescould,forexample,contributemoretotheappropriatemanagementoflongtermconditionsinpartnershipwith,orasanintegralpartof,bodiessuchasGPFederationsand/ororganisationssuchasMCPs.

To be cost effective, this will almost certainly requirethem to become an alternative direct source of sometypesofcarecurrentlyofferedinGeneralPractice,ratherthanmerelyaproviderofservicesaimedataugmentingwork that continues to be done by GPs and theirimmediatecolleagues.There isgoodreasontobelievethatasITbasedlinksanddiagnosticandothersupportinstrumentsbecomeincreasinglyavailableinpharmacysettingsandinplaceslikeresidentialandnursinghomes,pharmacistswill –subject to regulatory restraints–beable to offer a progressively widening range of directaccessillnessandpreventiveservices.

With regard to supplementary and independentpharmacistprescribing,adegreeofprogresshasbeenmadeintheUKoverthecourseofthelastdecade.Butdespitetheimportanceofmedicinesandmedicinesuseexpertise to the identity of pharmacy as a profession,it is arguable that more significant advances have

Funding and strategic direction from NHS England and LATs

Figure 10: A future model for NHS primary/community health and social care

Community pharmacies

GPs with integrated nursing, pharmacy and social service professionals

Budget holding primary

health and social care Federations,

with additional local services

Trusts with specialised diagnostic

and treatment services

General practice

Funding, monitoring and

feedback

LACCG

First contact level

Residential care

homes

Service users


to date been made in the field of nurse prescribing.Internationally, it could also be said that pharmacyprescribinginEnglandisnotasfarasadvancedasitissettingssuchas,forinstance,AlbertainCanada.

Theextentofsuchdifferencesshouldnotbeexaggerated(see, for instance,MakowskyandGuirguis,2014).Butit may be concluded that for future ‘pharmacy first’10policiestobeeffectiveitwillbeessentialforcommunitypharmaciststobeabletocombineextendedprescribingcompetencies with their dispensing management andsupervisory capabilities.Relaxations in regulations thatpresently prevent independent local NHS pharmaciesfrom sharing the use of robotic dispensing machinesisoneexampleof the typeof reform thatmight fosterfutureserviceimprovements.

Important progress towards transforming primary careprovision is already taking place in ‘Vanguard’ sitesand inanumberofother localities (Shortt,2015).Theefforts of agencies like the RCGP, the NAPC and theRoyal Pharmaceutical Society are also of value. It isencouraging,forinstance,thattheNationalAssociationforPrimaryCare’s initialPrimaryCareHomeproposalshavereceivedsupportfromNHSEngland.Otherrelevantinitiatives range fromtheestablishmentofpooled localhealthandsocialcarefundingsystemsthroughtorecentplans for a new voluntary General Practice contract.This could, in return for extended commitments toseven day service provision, offer a less bureaucraticoperatingenvironmentforGPsandhelpfosterschemessuchasthoseinvolvingpharmacistsmorecloselyinthemonitoringanddeliveryofpatientcare.

Inthefieldofcommunitynursing, innovations like–forinstance – the establishment of ‘virtual wards’11 andcommon systems of IT based health and social carerecord keeping also promise enhanced performance.Whatever the failures and distractions of the past,the need to invest in primary health and social careimprovements is now recognised at the national levelaswell as in an increasing number of localities, albeittheamountsoftimeandfinancialandhumanresourceneeded to establish more appropriate cultures andgreaterlevelsoftrustandinter-professionalcollaborationshouldnotbeunder-estimated.

Examplesofexcellentpracticealreadyexistthroughoutthecountry.Yetsustainableprogressmayprovedifficulttoachieveinareaswhichhavebeenlesslikelytoattract‘champions’ for new ways of working. From a broadsociological perspective resistance to change is oftengreatestinsettingswherepeoplelacksharedconfidenceintheirabilitytoadoptinnovativewaysofworking,and

10Thatis,policiesaimedatencouragingmorepeopletoinitiallypresentfordiagnosisandtreatmentin‘healthylivingpharmacies’orsimilarsettings.

11Whichallowpeoplelivinginthecommunitytotemporarilyreceive‘hospitalathome’support

mighthavemorereasonthanmosttodoubttheintegrityof thoseadvocatingchanges likehospitalbednumberreductions.

Effectivechangestrategiesarethereforelikelytopermitsignificant degrees of variation. From a social theoryperspective voluntarily led and accepted communityprogress is likely to be plural rather than regimented.Unduecentralisationcancreate ‘dependency’culturesthatsapentrepreneurialismand inhibitchangethroughover-rigid remunerative and regulatory structures.Nevertheless,manymembersofthepublicexpectandvalueserviceconsistencybetween localities,andtherearedangersthatintheabsenceofadequateinterventionsthat provide national direction and the sustainedincentivisationofagreedprimaryhealthandsocialcareimprovements, NHS development will continue to bepatchy and variable to an extent which confuses anddismays a significant proportion of its users. Withoutconsolidating action, even performance in exceptionalareasmay in time slip backwhen charismatic leadersleave or special funding arrangements (andwith themthe‘Hawthorneeffects’likelytobeassociatedwithpilotprojects)cometoanend.

Suchobservationspointtothepotentialvalueofrevisednation-widepaymentsystemsthatrewardandnormalisecross boundary data sharing and ‘joined up’ servicedelivery, as opposed to ‘silo’ working and sectional-interest focused ‘business as usual’ attitudes (PorterandLee,2013).SuchmeasurescouldprovevaluableinfacilitatingmoreeffectiveworksharingbetweenGeneralPracticeandCommunityPharmacy,aswellasinhigherprofile contexts such as improving health and socialcare coordination in order to facilitate earlier hospitaldischarges. Without measures that effectively createincreased capacity in General Practice for the supportofpeoplewith relativelycomplex requirements itwillbedifficulttoachievesignificantchangesinhospitalutilisation.

However, financial incentives are not the only drivers ofculturalandfunctionaladaptations.IntheNHSindividualsandgroupsandlocalgovernmentalsoneedtoresolvearangeofethicalandvaluebaseddichotomiesthathaveinthepaststoodinthewayofbettercarecoordinationandproductivejointworking.Issuesthatshouldbemoreopenlydiscussedandbetterunderstoodinclude:

• Access ‘versus’ continuity? The available researchpoints to tensions between meeting calls for rapiddiagnosisandcarewhenindividualsareinacutedistressorseekingtomanagecommonproblemsthatmaybediscomfortingbutareperceivedasnormaldailymatters,as against requirements for ‘high trust’ personal carethatarelikelytodemandcontinuingrelationshipbasedresponses. The latter aremost neededwhen peopleare facing potentially life threatening or life changingdifficulties. Coping with the latter can be seen as‘special’inthatitcallsforidentityshiftingpsychological


and behavioural accommodations. All health systemsstruggle with providing services to meet these twodifferent types of need in an empathetic, adequatelycoordinatedandaffordablemanner.

Thereisacaseforsayingthathealthserviceusersshouldbeseenby theirGPsevenwhen theyareexpressing‘common care’ needs, in order to build therapeuticrelationshipsandmutualunderstanding.However,thereisalsoanobviousriskof‘swamping’GeneralPracticewithtaskssuchastreatingtransientinfections,providingimmunisations and managing conditions like ‘normal’hypertension,stablediabetes,asthmaorCOPD.

Larger general practices may manage this tensionby differentiating between service provision by apatient’s ‘own doctor’ and care offered by otherstaff.However,frombothaserviceuserandapublichealthperspective,buildingarrangementsviawhichproviders such as community pharmacy basedstaffcansafelyandcosteffectivelyofferconvenient‘pharmacyfirst’accesstopreventive,diagnosticandcommon illness treatment services is a potentiallydesirableway forward. Thiswill be particularly so ifitcanbeachievedinwaysthatenhancetheintegrityofthehealthrecordsavailabletoGPsandtheirlongtermrelationshipswiththepeopletheyserve.

• Large integrated systems ‘versus’ small diverse organisations? As previously noted, this is animportanttopicinthecontextsofbothgeneralpracticeandcommunitypharmacy.Largerserviceprovidersarebydefinitionlikelytobebetterabletorealisebenefitsassociatedwiththedeliveryofcareatincreasedscale,evenifinpracticethisgoalisnotnormallyachievedviamergers and ‘take-overs’. Yet there is also evidencethat small organisations can provide environmentswhicharelessbureaucraticandinwhichitiseasiertooffer support that is experiencedaspersoncentred.ItcanbearguedthattheUKappearstoberelativelystrongly focusedon forming largeorganisationswithmarkedlyhierarchicalpowerand rewarddistributionsas compared with other European countries, albeitthere is also evidence that the performance ofNHSdoctors in communicating effectively with individualpatientsisrobustininternationalterms.

Despitethetraditionalroleofindependentpractitionersin the primary medical and pharmaceutical caresystems,12 the NHS may have been less orientedtowardsthepursuitofbenefitslikelytobeassociatedwith small professionally led organisations workingin circumstances which encourage effective

12Communitypharmacyistoanincreasingdegreeprovidedvialargeprivatewholesalerownedchainpharmacies,whichputspharmacistsinadifferentpositionfrommostGPs.Businessprocessescanbedesignedat‘higher’organisationallevelsareperformancemanagedthroughtodelivery.However,suchapproachesmaynotbesuitablefortheprovisionofpatientcentredpersonalcareinrelativelycomplexsituations.

collaboration than, say, its French or Belgiancounterparts.13 To the extent that this conjecture istrue,multiplesociologicalandeconomic factorsarelikelytounderlieit.ButforthepurposesofthisanalysisthekeypointtoemphasiseisthatapproachessuchastheformationoflocalHealthCareFederationsandthe NAPC’s ‘complete clinical community’ concept(Chana,2015)seektobridgethe‘largeversussmall’organisation divide. Their goal is to combine thebenefits of personal relationship based transactionswithsystemicallyembeddedcompetencies.

The practicalities of achieving local and/or nationalremunerationandgovernancearrangementsthatcantranslatethispromiseintoaday-to-dayrealityhavenotyet been fully addressed.However, recent researchontopics like increasingproductivityviaestablishingself-managedorganisations(Laloux,2014)suggeststhatmeaningfulprogressinthisdirectionispossible,shouldthestakeholdersinprimaryhealthandsocialcarebeadequatelymotivatedtoseekit.

• Managerialism ‘versus’ professionalism?Followingonfromtheabove,themanagerialrevolutionthat has to varying degrees occurred in developedcountry health services since the 1960s remainscontroversial,as istheroleofnon-clinicalmanagersindirecting thedeliveryofgoodqualitycare.To theextent that health professionals are not trusted toservepublicinterestsinoptimisingthevaluederivedfromhealthcareresources(Porter,2009)orlacktheorganisationalskillsneededtoachievebetterservicedelivery, a competentmanagerial cadre is required.Yet non-clinical managerial groups can developcounter-productive vested interests and lack insightintokeyaspectsofserviceprovision.Itisarguable,ifalsocontestable,thatonlypeopleinvolveddirectlyindeliveringcarearegenuinelywellplacedtocoordinatetheprocessesofinteractionneededtoachievegoodmedicalandwiderhealthandsocialoutcomes.

Inrecentdecadesmanycommentatorshavestressedtheneed toclosely involvehealthprofessionalsandservice users alike in care quality management inorder tohelpmaketheNHSaresponsive, learning,organisation (Berwick, 2013). New Federation/PrimaryCareHomebasedapproachestothedeliveryofwell-coordinatedhealthandsocialcarecouldhelpachievethisend,eventhoughtherecanbenosimpleresolution to the challenges inherent in enablingskilledandhighlymotivatedpeopletoworktogether

13FromaconstitutionalperspectivetheprimarymissionoftheNHSmaybetakentobemaximisingpublichealth,ratherthanassuringindividuals’rightsofaccesstoeffectivetreatments.Existingmanagementandfundingarrangementsreflectthis,albeitwithinafragmentedneo-liberalinstitutionallevelNHSgovernanceframework.Itcouldbesuggestedthatoptimallyeffectivehealthandsocialcaresystemsarelikelytoembodyvaluesthatgiveprioritytoprotectingthewellbeinganddignityofbothpatientsandhealthcareprovidersasindividualsinsociety,ratherthanasunitsthatcollectivelymakeupmoreimportantentities.


inwaysthatallowtheresourcescollectivelyavailabletothemtobeusedinwaysthatoptimiseoutcomesforserviceusers.

• Population health ‘versus’ individual care?Despite the work of pioneers such as Julian TudorHart (1971), traditionalmedical and pharmaceuticalcaremodelscanbecomeundulyfocusedontreatingindividuals as distinct from addressing communitywide determinants of heath and illness. At thesame timepublichealthbasedapproachesmayonoccasions be accused of sacrificing personal carestandardsandpreferencesinthepursuitofpopulationlevelhealthimprovementopportunities.

Such conflicts may be most likely to occur whenresourcesare limitedandmultipleunmethealthandsocialcareneedsexist,evenifaffluencecanalsobeacauseofperversebehaviours.Whatcanbesaidwithconfidence is that in developednations like theUKgoodqualitycare forboth individualsand theentirepopulation should be achievable, despite claimsit is in danger of becoming unaffordable. In realityperhapsthegreatestrisk isthatfailurestomeettheexperiencedneedsofallserviceusersandcommunitygroupsinfairandempatheticwaysmightinthelongtermunderminepoliticalsupportfortheredistributivefundingmechanismsrequiredbyuniversalhealthandsocialcaresystems.

Ensuring that care investment and delivery choicesare as far as possible taken with, rather than for,communities, and are at the same time informedbythebestavailableevidenceandanalysis, is likelyto offer the most productive approach to assuringdecision making that is perceived as reasonableand just. The extent towhich this canbe achievedbyauthoritiesthatareremotefromserviceusers,orbygroupsthat lackcredibilityastotheircapacitytounderstand both the biological and psycho-socialaspectsofhealthandillness,isinevitablylimited.

• Self-care ‘versus’ professional care? Traditionalprofessionaleducationcanonoccasionsencouragebeliefs to the effect that health and social care issomething that is ‘done’ to passive patients byqualifiedstaff.Inreality,desiredhealthandsocialcareoutcomesarenormallyco-producedbythecombinedeffortsof serviceusersandproviders, coupledwithinformal inputs from other community members.Thisisastrueinfieldslike,forinstance,orthopaedicsurgeryandtheeffectiveuseofanticancermedicinesas it is in areas such as community nursing or theprovision of smoking cessation support and otherpreventiveinterventions.

Free-standing community pharmacies are animportant source of self-care products and advice.Failurestolinkpharmacybasedworkattheinterface

betweenself-careand theprofessional treatmentofillnessmore robustly to the ‘mainstream’deliveryofmedicalcarebyGPsandotherhealthprofessionalscould miss important opportunities for the furthertransformation of services and the better use ofresources.

Dispensingmedicines via the existing disseminatednetwork of Community Pharmacies (at present 90percentofpeopleinEnglandlivewithin20minuteswalkofapharmacy, rising toclose to100percentinurbanareas–Toddetal,2014)currently–alongwithrelatedservices–costsEnglishtaxpayersintheorderof£2.5billionperannum.Somecommentatorsbelieve that this sumcouldbe significantly reducedby computerising the transmission of prescriptionsandconcentratingdispensing in factory/warehouse-like facilities. Most medicines and allied productscould, the proponents of this approach believe, bedelivereddirectlytopatients’homesortofacilitieslikeGPsurgeriesorcollectioncentresinsupermarketsorotherretailoutlets.

There is evidence that such strategies can savecosts and/or release pharmacists’ time for clinicalwork. However, the net savings such measuresare likely to generate are – assuming that an easilyaccessible capacity to provide the 25 per cent orsoofallprescription itemsclassifiedas ‘acute’ inatimelymannerispreserved–likelytobeconsiderablyless than is sometimes suggested. Rather thanweakeningtheexistingCommunityPharmacyservicetoapointwheresignificantnumbersofpeople losegoodphysicalaccesstodispensingandothervaluedservices amore cost effective strategy could be tomoveasrapidlyaspossibletowardsextendinghealthcareprovision in local pharmacies,both to improveserviceaccessandreducepressureselsewhereintheNHS.

Somedecisionmakersmay fear negative reactionsto such policies, especially if more vigorously ledattempts to realise this optionwere to bepursued,andsomesectionalinterestsmaywishtoexaggeratesuch concerns. But both doctors and patientrepresentatives interviewed during the qualitativeresearchundertaken for this report agreed that thiswayforwardshouldnowbepro-activelyexplored.

Towards value based care

TodateNHSleadershaveoftentakenadisappointinglybinary (‘one side or the other’) approach to resolvingthe dichotomies outlined above. At the same timeinstitutionallyfocusedgovernancebodiessuchasTrustBoardsandinadequatelyinformedcommissioningbodieshavefrequentlylackedacomprehensiveunderstandingofhowbesttoservepublicphysicalandmentalhealth


interests.With thepossibleexceptionofmore ‘marketled’ care providers such as community pharmacists,itmight alsobe said that serviceuser ‘wants’ are toooften seenas false signals thathealthandsocial careproviders should ignore in order to concentrate onmeeting‘legitimateneeds’.

However, inOctober2015theChiefExecutiveofNHSEngland,SimonStevens,endorsedapilotprogrammefor care delivery based on the ‘Primary Care Home’model (Roberts, 2015). Pursued appropriately, suchstrategiescouldnotonlyhelptofurtherdevelopbetterco-ordinated ‘close to home’ care for patients but inaddition create opportunities for more sophisticatedapproaches to balancing individual and communityrequirements.

As already noted, NHS England has also recentlyannounced funding for the experimental employmentof several hundred clinical community pharmacists inGeneralPractice.This is adesirable step forward thatmight in time help overcome some of the workforceproblems currently affecting primary care provision.However, it should not be used to justify neglectingthe wider development of Community Pharmacy, ordiscourage the addressing of questions like ‘how can the existing body of community pharmacies and pharmacists be enabled to take a progressively more active part in local primary care Federations?’.

There iscurrentlyconsiderable interest inreformssuchas what is (in some respects potentially misleadingly)termedthedevolutionofhealthandsocialpolicymakingandservicedeliveryresponsibilitiestolocalauthorityledregional bodies. Themost notable example of this todateexists intheGreaterManchesterarea.Advocatesofthebudgetandcommissioningresponsibilitypoolingthat thiswill result inbelieve itwill integratehealthandsocialcare,andgiveelectedlocalcouncillorsastrongerroleindirectingservicedevelopments.

Thiscouldpermit innovativecontractingorotherformsof service funding and in theory at least allow serviceprovisioninEnglandtobecomemorelikethesystemthatexistsinStatessuchasSweden(Box8).Thepotentialimportance of such reforms should not thereforebe ignored (McKenna and Dunn, 2015). However,simplisticattemptstointroducetheminwaysthatignoreimportantculturalandalliedsuccessdeterminantsmustbeguardedagainst.

SomecriticswarnthatwithoutexplicitsafeguardssuchstepsmightintheUKinfutureleadtostrictercashlimitsonoverallhealthandsocialcarespending(legally,localauthorities cannot operate with annual deficits) whileat the same time reducing national level pressures toincrease public health and social care outlays on thecareofpeoplewithconditionsrangingfromcancerstoAlzheimer’s Disease to advanced Western European

levels.Anothercauseforconcernisthatastrengtheningof local political control in the health sphere could insomecircumstancesblockthedevelopmentof‘PrimaryCare Homes’ and services provided directly by localprofessionalsinwaysthatmakethemmoredirectlyandfullyaccountabletotheirindividualusers.

There are allied uncertainties surrounding the futureroleofCCGs.Someobserversarguethattheyarenotconsistentlyfitforpurposeinrelationtocommissioningsecondary level hospital care, or community servicesother than,perhaps, narrowlydefinedprimarymedicalcare.EvenintheGeneralPracticecontexttheabilityofmostCCGstoacthasuntilrecentlybeenverylimited.

DevelopmentssuchasthoseinManchesterandrecentlyinCornwallmightintimeleadtonewstructuresthatwillreplaceCCGsastheywereestablishedin2013.Likewise,in some localities the emergence of fully integratedprimary and secondary NHS provider organisationsabletotakecomprehensiveresponsibilityfordevelopingservices in their localitiesmight alsoeventually lead tofurther reforms in,oreven theabolitionof, thecurrentEnglishNHScommissioningarrangementsbasedonapurchaser/providerdivide.

However,thepastrecordofserialstructuralchangesintheNHSisnotencouraging.RemovingorradicallyreshapingCCGsbeforetheyhavehadtimetobecomemorefirmlyestablishedanddefinehowbesttheycanfunctionmightwell have perverse consequences, not least becausethere are presently important opportunities for furtherextendingtheirroles.Theviewtakenhereisthereforethatthe most productive approach from a health outcomeimprovementperspectivewillbetofocusondevelopingPrimaryCareFederationsinwaysthatwillallowthemtoacteffectivelyasbudgetholdingcomprehensiveservicedelivery organisations, working with CCG support andsecondarycarehospital involvementas localconditionspermit.

Achieving thiswill very probably demand amixture of‘soft’ and ‘hard’ interventions. Examples range fromthe further encouragement of public and professionaldebateaboutthefutureofprimarycarethroughtothefinancial incentivisationofbetter jointworkingbetweengeneralpracticesand independentlysitedpharmacies.Importantquestionsastohowthiscanbestbedoneinwaysconsistentwithpatientandpublicinterestinchoice,aswellasintechnical,allocativeandsocialefficiencyandthe improvement of professionalmotivation, remain toberesolved.Buttheyareatleastbeginningtobemorefullyconsidered.

EvenifeachcommunitypharmacyinEnglandwereonlyable–overandabovetheircurrentcontributions–totakeon10percentoftheaveragegeneralpractice’sexistingclinicalandalliedworkloadover,say,thenextfiveyears,


this could release approaching 5,000 GP FTEs14 andsimilaramountsofpracticestafftimeforotheractivities.Giventhechallenges facingtheNHS, thepossibilityofgainsofthismagnitudeshouldnotbeoverlooked.

For some, the barriers still to be overcome in orderto achieve such transformative progress may seemdaunting.But theoriginalNHSwaseffectively created

14Fulltimeequivalentworkforcemembers

inthetwobleakpost-waryearsbetweenthepassageoftheNHSActinNovember1946anditsestablishmentinJuly1948.Seenfromthisstandpoint,taskslikefurtherimproving jointworkingbetweenGeneralPracticeandCommunity Pharmacy to provide better care accessandopenthewaytoenhancedhealthandsocialservicecoordination should not, in today’s relatively benignsocialandeconomicenvironment,proveinsuperable.

Box 8. Health and Social Care in Sweden

Aswith the NHS in the UK, health care provision inSweden(whichinpartbecauseofitswartimeneutralityestablished its modern era system before Britainwasabletosointhelate1940s) isauniversalpublicservicefinancedfromtaxation.As inthiscountryandmostotherWesternEuropeannations,patientchoiceand competition between alternative providers haveincreasingly become seen as important priorities,whilepublicmonopolyprovisionisnolongerregardedessential. But unlike the situation with the NHS,Swedishhealthcareprovisionisbasedontheprincipleofsubsidiarity.Thisrequiresresponsibilityforfinancingand ensuring appropriate standards to lie at thelowest possible local government administrative level(Bidgood,2013).

Swedenspends9-10percentofitsGDPonitpubliclysupportedhealthsystem.ThisisalittleabovetheBritishlevel.About70percentofthissumisraisedbythe21countiesand290municipalitiesthattogetherservethecountry’s9millionpeople.Localchargesareoftenleviedataflatrate,butcentralgovernmentgrantsfundedbyprogressivenationaltaxationservetoevenoutresourceinequalities. Primary care is delivered by more than1100public(ownedbythecountycouncils)andprivate(mostlyownedbycompaniesorcooperatives)PCOs.Team-basedprimarycarefacilitieswithfourtosixGPstogetherwithdistrictnurses,nursesanddependingonlocalneedsphysiotherapists,occupational therapists,psychologists,andsocialwelfarecounsellorsrepresentthemostcommonpracticemodelinSweden.

Another important characteristic is that, as opposedto the UK position, publicly supported social care inSweden is better funded and of significantly higherqualityacrossarangeofareas,including–forinstance– the provision of residential care for older peopleliving with disabilities. Whereas Britain spends onlyaboutonepercentof itsGDPonsuchsupport, theequivalent Swedish proportion is in the order of 3percent.Recentchangesannouncedafter the2015ComprehensiveSpendingReviewmayprovesufficienttochecktherelativedeclineinsocialcareprovisioninEnglandseeninrecentyears(seemaintext).ButtheywillnotcontributetoclosingthegapbetweenSwedishandBritishpublicinvestmentlevelsinthiskeyarea.

Theextenttowhichsuchdataarefullycomparableisquestionable. It would be wrong to over-emphasise

theextenttotheSwedishwelfaresystemasawholehasoutperformedthatoftheUKoverthelastseventyyears.Insomeareas,suchassuccessfullyassimilatinglarge migrant populations with plural care and alliedneeds,Britainmayhavedonerelativelywell.However,from an ageing population perspective a persistentweakness at the heart of the NHS and its partneragencies has been the inconsistency between ‘free’medicalandalliedserviceprovisionand the fact that‘social’ care for people with conditions such as (forexample)dementiashastypicallybeenchargedforuntilindividualorsometimesfamilyfundshaveineffectbeenexhausted. This has on occasions created perverseincentivestoclassifyhealthcareassocialcare,whichperhapshelpsexplaintheNHS’schequeredrecordofcommunitynursingserviceprovision.

Atothertimesithaseitherdriventheavoidableuseof,or ‘blocking’of, relativelyexpensivehospital facilities.Moreadequatecommunityprovisionscouldmoderatesuchproblems,whilesimultaneouslydeliveringbetteroveralloutcomes.Itmaybesuggestedthathealthandsocialcare ‘integration’could in futureeliminatesuchproblemsinEngland,andthereisevidencethattheco-locationofprimarycareworkersofall types togetherwith development of good personal relationshipsand cooperative cultures can generate importantadvantages.However, if no adequate solution to theunderlyingchallengeofresolvingthedisparitybetween‘means tested’socialcareprovisionand ‘free’healthcareisfound,formingstructurallyunifiedprovider-sideagenciesinthepursuitofbettercarecoordinationmayinpracticeprovelittlemorethan‘magicthinking’.

ItisalsoofnotethatinSwedeneffortshavebeenmadetodistinguishbetweentheprovisionofhealthcareasabio-medicalfunctionascomparedtosocialcareasbeinganactivityaimedatenablingsatisfactorywaysoflifetobemaintained,andprotecting individualchoiceand required levels of personal autonomy in everyaspect of existence (Lindström Karlsson, 2015). Therhetoric of bio-psycho-social care may suggest thatconfusionsbetweennursingandsocialcarecaneasilybe avoided. Yet inadequately informed attempts toconflatethetwomighthaveunwantedconsequencesthat are more difficult to avoid than is commonlyrecognised.


ConclusionTheNHSremainsoneofthebetterorganisedandresourcedhealthcaresystemsintheworld.ButtomeetthetwentyfirstcenturyneedsofpeopleinEnglandandtheotherUKnationsaswellaspossiblewithintheresourcesavailableitwillhavetoimproveitscapacitytoofferconvenientaccesstopreventiveand‘commonneed’diagnosticandtreatmentservices topeople at all stagesof their lives. There is inadditionagrowingrequirementforwell-coordinatedsocialandhealthcaretoprovidemorecomplexpersonalsupporttopatientsathighriskofsufferingavoidableepisodesofserious illness and ultimately losing their independence.Although there isevidence that in international terms thecurrentperformanceoftheUKisalreadybetterthanthatofsomeotheradvancedcountries,further improvementsshouldbepossible.

Enhancingprimaryhealthandsocialservicesoffersanimportant key to raising the performance of the entireNHS. As the UK’s demographic, epidemiological andsocial transitionscontinue,and innovativetechnologiesoffernewcommunicationandtherapeuticopportunitiesforbothprofessionalsandindividualsseekingtomaintaintheir own health, the balance of care provision willinevitablyshift.Butachievingoptimalchangewillrequiregood insight,carefulplanningandfirmcommitment tomeeting personal andwider public requirements at alllevelsofthehealthandsocialcaresystem,fromthoseoffamiliesandlocalpractitionercommunitiesthroughtospecialisedhospitalcareandcentralpolicymaking.

The unique universal care attributes of British generalmedical practicemeans that it can serve as a centralplank for continuing NHS development, based onboth trusting relationships with individuals and insightinto the needs of local communities. There is also alarge, if fragmented, body of evidence indicating thatCommunityPharmacycanbeneficiallyplayanextendedpart in delivering accessible health care, aswell as intaskssuchasreducingprescriptionerrorsandfacilitatingbettermedicinesuseamongstprioritygroups.IfGeneralPracticeandCommunityPharmacycanmoreeffectivelycombine their contributions this would open the wayto both better public health and significant overallNHSefficiencygains,whatevertheuncertaintiesofthefinancialenvironmentthatliesahead.

Some movement towards this end has already beenachieved.However,nohealthservicehasyetachieveddefinitive system-wide progress towards realigning theworkingrelationshipsbetweencommunitypharmacistsanddoctorsinwaysthatreflectthefulllevelsofgainthatpilot schemes and local examples of excellence showarepossible.

InEnglandandelsewherethefundamentalreasonsforthis apparent ‘road block’ include lagged consumerexpectations, cultural differences between the

professions and historically rooted variations in theways community pharmacists and GPs are educatedand remunerated. These differences reflect importantdistinctionsbetweenthetasksofoptimisingmedicinessupplyanduseandthatofdeliveringholisticclinicalcare.Yetbarrierstocloserjointworkingarenowfading,alongwithsomeifnotallofthetraditional–inpartsocialclassdefined – boundaries between medicine, pharmacy,nursingandsocialworkinheritedfromthepast.

ThepromiseoftheNAPC’sPrimaryCareHomemodelisthatitoffersaroutetowardsestablishingbetterlinkedfunding arrangements for local community medical,pharmacy and nursing services, and a platform forcoordinating health and social service provisions. Theextent to which progress towards this end could andshould be facilitated by adaptive national contractsas distinct from multiple unique local agreementsis presently uncertain. But constructive change willbe possible if public and sectional managerial andprofessional interestsareadequatelyaligned,andGPsand pharmacists are sufficiently motivated to takeeffective action. For independently sited communitypharmacyinparticularafailuretoinvestsufficienteffortin establishingbetter integratedprimary careprovisionwould–whatevertheperceivedhazardsofpro-activelyseekingchange–almostcertainlyresultinreductionsinitsstandingandrole.

There is a need for individual health professionals toacceptriskand leadpurposefulservice improvements.Unduedependencyoncentral leadership isunlikely togenerateviablenewhealthcareparadigms.Successfulprogress towards the formation of well aligned‘completeclinicalcommunities’involvingallprimarycareprofessionals will be a significant step in the ongoingevolutionofthiscountry’shealthandsocialcaresystem.Itmightalsohelpguidethedevelopmentofcosteffectiveuniversalhealthcareinothernations.

However,havingrecognisedthevalueoflocalinnovationandenterprise,nationalrecognitionoftheimportanceofsupportingbetterprimarycareprovisionisalsovital.Oneofthekeyconclusionsofthisreportisthatestablishingmoreeffectivelylinkedfinancialincentivesisavitalpriority.Without these there is a danger theNHSwill, despiterepeated superficial changes, remain ‘frozen in aspic’and–insomewayslikehealthcareintheSovietUnionin its last decades – ultimately fail, not because of itscostbutthroughfailurestoevolveinwaysthatbuildonthe inherentstrengthsofGeneralPractice,CommunityPharmacyandothercommunitycareresources.

Working together

Beyond the big issues of cultural change, relationshipbuildingandtheappropriatefinancialsupportofhealthand (currently means tested) social care, prescribing


anddispensing liecloseto theheartofwhatGPsandpharmacists provide the public. Taking medicines isalonerarelyacompletewayofresolvingserioushealthproblems,evenwhenconditionsarecorrectlydiagnosedandeffectivedrugsareappropriatelyused.Nevertheless,optimising thesupply,prescribingandconsumptionofpharmaceuticalproductsisacentralpartofgoodday-to-dayhealthcare.

In thepast therewerepublic interest focused reasonsforstrictlyseparatingdispensingfromtheprocessesofdiagnosisand therapyselection.Yet in the twentyfirstcenturyadvancesinareassuchaspublicunderstandingof health and disease, professional education, healthsector regulation and the computerisation of not onlyhealth and social care record keepingbutmanyothercarerelatedprocessesarecreatinganewenvironment.IntheNHS,stepstowardspharmacistprescribinghavebeentakensince2000.Buttheevidencepresented inthis analysis indicates once again thatmore could beachieved.

IfinfuturetheskillsofpharmacistsandthepotentialoftheestablishedNHScommunitypharmacynetworkare–asopposedtobeinglostorwasted–tomoreeffectivelyboost thecapacityofprimarycareasawholeandsoallowtheNHShospitalservicetofunctionasefficientlyand effectively as possible, enabling all communitypharmaciststobeindependentprescribersfor‘commoncause’complaintscouldwellprovecentrallyimportant.A secondcentral conclusionof this report is thereforethatfurtherextendingpharmacyprescribingoutsideGPsurgeries in ways that strengthen rather than weakenthe ability of family doctors’ and their practice teamsto provide first class individual and population care,and which also optimise the cost effectiveness andaccessibilityofcommunitypharmacymedicinessupply,shouldbeseenasintegraltothesuccessofthefutureNHS.

Inthefinalanalysis,promotingnewandmoreeffectivewaysforlocalprofessionalstoworktogetherinordertoprovideserviceshasmuchtooffernotonlyserviceusers,but also everyone working in health and social care.A great deal of the responsibility for developingmoreeffectiverelationships lieswiththe immediateprovidersofsuchservices,oftenbecauseonlythey–inpartnershipwith service users – can fully understand the tasks inwhich they are engaged. But individuals and groupssuch as GPs and pharmacists alone cannot facilitatetheoverall service transformation that isnowrequired.Excellent national leadership and the establishment ofmore appropriate financial andgovernance systems isalsovitalforthesuccessofservicesasawhole,includingspecialisthospitalprovisionalongsidethatofcommunitybasedcare.

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