Analysis: Concerns rise as RSG proposals delayed

The story so far...

In November 2019, PSNC and the 69 local pharmaceutical committees (LPCs) in England jointly commissioned a National Independent Pharmacy Review of the profession’s national and local representation and the support it provides for community pharmacy contractors.

The Review team – led by David Wright, professor of pharmacy practice at the University of East Anglia School of Pharmacy – canvassed LPCs and contractors across the country about the structures, processes and roles of LPCs and PSNC. It then came up with 33 recommendations about how to make the national network structure work efficiently for contractors and ensure it is fit for the future.

Progress

In January 2021, the Review Steering Group (RSG) was tasked with producing a contractor-led and designed decision-making process for Professor Wright’s proposals to be put to the sector. It spent the rest of the year holding engagement sessions to get feedback from contractors in order to refine a proposal for a new system-wide model of representation and support at both local and national levels.

Delivering a progress update at the Pharmacy Show in October, the RSG said that overall engagement from across the sector had been “impressive”, with more than 5,000 people reading its emails and 11,500 visits to the RSG website at that stage – and more since then.

Amongst other initiatives, the RSG has held workshops and 13 focus groups to discuss how contractors should be represented in the new organisation, and what wider structure and governance is needed to ensure the local and national organisations are set up to deliver the best possible services to contractors. From these, it also got “overwhelming feedback” supporting the alignment of a future LPC network to integrated care systems (ICSs) in the new NHS structures.

The next stage is for the RSG to submit its proposals document for a contractor vote. In a recently published myth-busting and FAQs document, the RSG says its aim is to put forward proposals “that will be supported across all parts of the sector”, admitting that once its final proposals are published, “those proposals cannot be changed”. However, it adds: “If the sector votes against them, the RSG will have to think again”.

Parity and focus

Despite stressing its commitment to “produce a proposal that would have broad support, with direct involvement and open feedback from contractors”, the RSG is facing criticism.

Some quarters say it has not stretched its consultative reach as far as it could have, potentially creating a lack of parity. Others worry that the proposals may focus on transparency and governance rather than action, leaving many contractors unsure of what they are being asked to vote on.

Although “supportive of the principle of a review of representation structures”, the NPA has expressed concerns that “the way the review has been handled to date may lead to an outcome that proves to be unfair and has a lack of parity built into it”, according to Gareth Jones, the NPA’s director of corporate affairs.

“The Review Steering Group’s latest claim is that everything’s going swimmingly, but I still think the ‘fairness factor’ is not feeling quite right,” says Mr Jones.

“Yes, it may well have held lots of webinars, but if only 100 or so independents have attended, where does that leave the remaining 5,000-plus, and how can it judge if they’re going to be for the recommendations or not? Who has it truly touched? Because if you speak to almost all independent contractors at the minute, they say they are simply too busy to even think about this.”

Where the NPA does think the RSG has listened to its concerns is around the initial thinking that the best way to increase efficiencies would be to reduce the number of LPCs from 69 down to 15, each looking after 600 or 700 contractors at a regional level. “Thankfully, it has now moved away from that towards the idea that you need a kind of a placed-based match of LPCs with ICS,” says Mr Jones, “which could leave us with around 42.”

However, with the exact details still unknown, another concern for the NPA is the documentation of the proposals. “The RSG’s original line was that it was going to land a prospectus,” says Mr Jones, “which to us means a complete outline of what it is planning.

Yet it now seems that what it is actually going to put out is more like a proposal that will outline the direction of travel – to which I ask how do you expect people to vote by taking a leap of faith over all the inevitable gaps in the thinking? And as the NPA has not been at the table since day one, we also don’t know what the proposals contain.”

The voting system

Aside from what will be voted on, some have expressed concerns about the voting system itself.

The RSG plans to hold a single vote to approve (or not) its proposal. All contractors will be eligible to vote, with one vote permitted per ODS code, and all equally weighted. A two-thirds majority of all those casting a vote is required to approve the vote, with a target voter turnout of 66 per cent of the contractor base.

The RSG says that providing a single proposal for contractors to vote on “enables the sector to come together with a single voice and agree the way forward” and will provide “a clear mandate for change”. It says this approach aligns with the current practice used by the PSNC and LPC in seeking a two-thirds majority vote, while the addition of a high target turnout recognises the need for a high degree of engagement across the sector.

However, the Company Chemists’ Association (CCA) has a 40 per cent block of votes, which means that it only needs a small number of others to match its line – in whichever direction it goes – to achieve a majority.

The RSG says the turnout and pass rate targets are “sufficiently high to ensure that both CCA and non-CCA groups can influence the outcome should they have a different view to the others”. But NPA chair Andrew Lane says this proposed voting mechanism “falls short of what is needed to guarantee a way forward that commands the support of the whole sector”.

“Under these proposals,” says Mr Lane, “a very small number of large businesses could outvote thousands of independent contractors, effectively disenfranchising the independent sector.”

The “real world manifestation of this”, according to Mr Jones, is that “in essence, the larger companies are absolutely in the driving seat, either by voting ‘no’ or not voting, or if they want the proposals by voting ‘yes’ and only needing to drag a few more people along with them”.

The flip side is, of course, that if more than a third of contractors abstain from voting then the vote fails anyway.

Hurdles and delays

The initial long wait for Professor Wright to conduct his review and publish his recommendations has been compounded by pandemic-heightened delays to the RSG’s process.

“One could question whether the Review and the RSG is fit for purpose now the pandemic has changed the attitudes of commissioners, who are saying how much community pharmacy has delivered,” says Raj Matharu, chair of Pharmacy London.

“Maybe before we get to restructuring the representative bodies we need to have investment in the infrastructure of community pharmacy to address workforce issues,” he adds. “The RSG should have said how we can develop career pathways that can engage at neighbourhood, place and system level, and take people on to be national leaders.”

Mr Matharu also posits the need for “a strategy document looking at what we really want to do in community pharmacy”.

He says: “I want to empower our profession and to be considered as a profession, not as a trade. I want us to build relationships between pharmacists and the patient, focusing on our unique selling point of convenient access, and to have a framework in place that is able to deliver community pharmacy services at pace, at scale and consistently because everyone is really suffering at the moment and contractors are really swamped.”

Indeed, this unprecedented workload leads Mr Matharu to suggest a moratorium on the Review process. “Everyone is working flat out at the moment, serving our patients and we don’t have a moment to engage with the RSG,” he says.

“Let’s press pause, get the pandemic out the way, settle ourselves down and then we can get back to it. We have an opportunity to make sure the profession is vibrant and healthy, but instead of using that to say how brilliant we are and attract the right investment in infrastructure, we are looking at how we are going to organise ourselves, and this puts the spotlight backstage rather than front and centre.”

Richard Brown, chief officer at Avon LPC, is also in no rush. “Until we see what is actually being proposed, we still have a lot of priorities we continue to work on in Avon, and we have not changed our strategic direction plan,” he says.

“When there is a proposal to be shared we will all – trade bodies, LPCs , PSNC – have to do our bit to make certain all our contractors are informed about it in an unbiased way, as they are the ones who ultimately have to make the decision and must have the opportunity to engage with the process. But until then, what am I telling them?”

Complex collation

Whichever view you take, the findings of the Wright Review were complex and got mixed reactions across the sector, making the collation of a final proposal a far from easy task.

In answer to questions about why bodies such as the NPA and Pharmacy London were not at the RSG table with a direct voice, an RSG spokesperson says: “RSG members were selected late in 2019 based on terms of reference which were agreed between PSNC and LPCs. Members were put forward to represent all contractor types, including independents.

“All bodies are free to have direct communication both with the RSG as a group and with individual members of the RSG and we have engaged directly (through meetings and letters) with both the NPA and Pharmacy London.”

The RSG spokesperson says contractors have been involved in shaping its proposals through “an open and iterative process from the start”, but adds that it has had mixed feedback on what its proposals should look like. “Some contractors want a summary document that does not take too much time to read and digest, while others want significant amounts of detail,” they say.

“We hope to cater for both of these and to offer a concise document, with further information available in appendices for those who want it.”

However, before we get to that point, the RSG will have a further round of engagement events, followed by the use of digital communications to share proposals and allow for contractor questions.

“The RSG is very cognisant of the need to reach conclusions soon, given the rapidly approaching changes in NHS structures and a desire to begin the change process ahead of the negotiation of the community pharmacy contractual framework (CPCF) following the end of the five-year deal,” says the spokesperson.

They add that even then, the vote is only the beginning of the change process to come: “A clear view from contractors will set a strong mandate for change, but it will then be for LPCs and PSNC to agree their ways forward”.