NHS Community Trusts - how do they affect

Acute Trust pharmacy managers?

Introduction

Over the last five years, many areas in the UK have seen the establishment of NHS Community Trusts as independent 'players' in the NHS field. This trend has been driven by the need to protect directly-managed resources for primary care and community services in order to move towards a primary care-led NHS'. This evolutionary process has not been without incident; all too often the split away from Acute Services at local level has been difficult and acrimonious, resulting in lingering resentment between managers of the respective Trusts. Only after several years of separate development may this effect diminish. It is against this background that pharmacy managers may find themselves negotiating with a Community Trust to provide pharmacy support.

Market pressures have led to some amalgamations, to produce larger and more viable units. The trend is for these to be within non-acute care, e.g. two Mental Health Trusts merging or a Mental Health and a Community Trust. Central Government does not favour integrated acute/community Trusts, as a result of the historic tendency for community-based services to be drained of resources when linked to acute care. Tempting though it might be to predict the re-emergence of district-wide structures, this is unlikely to be model for the future.

This new type of Trust, whatever its portfolio of services, will need to obtain pharmaceutical advice and support. A few larger Community Trusts have established posts for their own pharmacy managers at the outset; accountability for service delivery is then clear. The majority of Community Trusts however continue to obtain their pharmacy services from another Trust. This paper examines the implications of this for pharmacy managers within acute care, and models that can be adopted to ensure that Trusts are able to utilise the skills of pharmacists to best effect.

What services do NHS Community Trusts provide?

Typically, a Community Trust may provide any or all of the following:

Community Health Services
Mental Health Services
Support for people with learning disabilities
Services for physically disabled people
Community-based care for elderly people e.g. community hospitals

Details of local service patterns and developments will be described in Trust annual reports and business plans.

What are the implications of Community Trust activity for pharmacy managers?

The starting point for many pharmacy managers is that their department has historically provided pharmacy support to areas that are now managed by a separate Community Trust. Initially, pharmacy activity may be included in a block contract between the Trusts, but sooner or later there is likely to be a demand for a more explicit contracting arrangement.

This can arise;

As part of a market testing exercise (with or without other clinical support services)
In order to resolve existing problems and gain greater control over service delivery
To refocus the pharmacy service, e.g. to encourage a shift away from inpatient services
To secure better value for money
To reduce dependence on the Acute Trust
To consider in-house pharmacy services

Key questions that then need to be considered are:

1. Is the pharmacy activity provided to the Community Trust accurately documented? Has a service specification been agreed with the Community Trust?

Basic data on supply and dispensing workloads should not be a problem, but there may be more difficulty in collating data on advisory work. However this can be achieved through query logs, visits, data on training delivered, input to policy groups etc. The Community Trust may recognise the more diffuse nature of community-based activity and particularly value this area of pharmacy support.

2. Are the resources incurred in delivering this activity accurate known? Where do these resources currently lie?

Given the tensions between Trusts, few will accept without question costing data presented by Acute Trust managers. Pharmacy data needs to be convincing and accurate. If documented resources do not match current pharmacy activity, this will cause serious problems regardless of which Trust theoretically benefits.

3. Are recipients of the service sufficiently aware of what is currently provided?

During negotiations, Community Trusts may canvas their service managers' views on pharmacy services received. This can be revealing both to the pharmacy manager (who may not be very familiar with the activity his staff provides off-site) and also to the Trust management. The case for continuing to provide and develop advisory support to community-based staff can be strengthened by this exercise.

4. Does the acute hospital wish to continue to provide the service?

Trusts of all kinds are increasingly being encouraged to focus on their core activity. If the Acute Trust has a strong in-patient focus, it may question the wisdom of continuing to provide a non-core service. There may be alternative providers which the Community Trust can be encouraged to consider. The resulting loss of income might be a disincentive, but must be balanced against the necessary investment of management time to secure the contract in future.

5. Is the establishment of an in-house pharmacy service or lead pharmacist a viable proposition?

From the pharmacy managers' point of view, this can at first appear to be serious threat, and a retrograde step in the context of hospital pharmacy development. However it is not pharmacy's view, but that of the Trust buying in pharmacy services, that will count in the end. It may be most helpful to consider this option from the point of view of the Community Trust.

An option appraisal for the future procurement of pharmacy services might be:

Option 1: Continue to contract with Acute Trust pharmacy for all services required.

Advantages	Disadvantages
Least disturbance to existing arrangements Continued access to full range of hospital pharmacy services, including clinical and professional support, and cover	Community focus absent if acute hospital pharmacy needs dominate Few effective levers to secure service quality or VFM Difficult for pharmacy advice to be effective at management level if not a Community Trust employee Potential conflicts of interest

This option may only be attractive to the Community Trust only if they are completely satisfied with existing arrangements and few changes are planned.

Option 2. Employ a lead pharmacist in the Community Trust as contract manager, and continue to purchase all other services required from Acute Trust pharmacy.

This can be an attractive option if the Community Trust wants to gain more control over services delivery but still wishes to continue to benefit from links to a large hospital pharmacy.

Advantages	Disadvantages
Lead pharmacist can effectively manage and monitor services received from all sources, with no conflict of interest Designated post can ensure that community focus extended to pharmacy services. Better integration with Community Trust staff. Lead pharmacist can contribute effectively to Community Trust strategic and development needs	Possible professional isolation of postholder Relationships and communication with acute hospital pharmacy staff must remain good for this option to work satisfactorily Any difficulties regarding separate must be covered in pharmacy contract e.g. access to computer system, shared on-call rota

Option 3. Set up in-house pharmacy service and access all support required from this source.

Advantages	Disadvantages
Complete control over resources and services received Pharmacy staff accepted as integral part of Community Trust Full range of services can be obtained through combination of directly employed staff and contracted-in support for specialist areas No conflicts of interest re. strategic advice Community focus for pharmacy services easily achieved	Duplication of services can be expensive in terms of staffing and drug purchasing. May be recruitment difficulties if posts perceived as unattractive Unlikely that full range of pharmacy services can be provided in this way Difficulties with staff cover. Any services physically based at acute hospital would need separate consideration.

This option will be attractive in larger Trusts, or where there is pressure to reduce dependency on an Acute Trust.

Option 4. End contract with Acute Trust pharmacy and contract with an alternative provider

Advantages	Disadvantages
Possible option if either Trust is determined not to continue the present contract arrangements Can lead to service improvements if high quality services are obtainable from neighbouring Trusts Possibility of existing staff transferring to new provider (e.g. mergers)	Loss of existing expertise which may take years to replace Problems with any services based at acute hospital site Transport issues Greatest potential risk of disruption to service delivery Risk of inaccurate or incomplete service costing by new provider, through lack of background knowledge

Unless the potential disruption to services can minimised, this option is unlikely to be favoured unless others have been unsuccessful.

What are the key elements of a contract with the community Trust to provide pharmacy services?

Provision of pharmaceutical products

Supply of pharmacy items held as stock
Dispensing service for inpatients, outpatients and community units
Procurement

Clinical and advisory services

Pharmaceutical advice, liaison and training delivery within community health services
A planned schedule of visits by pharmacist and/or technician to wards/clinics and locations
within the Community Trust
Clinical pharmacy support to patients and staff within the Trust
Drug information (e.g. bulletins, query answering etc.) services
Specialised pharmacy services if required e.g. Production, QC, etc.
On-call arrangements
Access to training support for pharmacy staff (inc. clinical)

Senior level advice

Provision for access to senior level pharmaceutical advice on strategic matters
Drug expenditure reports, DUR and DUE
Advice to any formulary or Drugs and Therapeutics Committee

Contract Requirements

Quality standards for service delivery
Payment arrangements, including recharges for drug expenditure
Monitoring arrangements

Does the pharmacy manager have a conflict of loyalties?

A difficulty for pharmacy managers is that the two Trusts involved may have radically different management styles and strategic directions. No matter how competent the individual may be, there will be occasions where a rival Trust will not seek his or her advice on strategic issues. Difficulties have arisen when pharmacy managers promote arrangements which are unacceptable to the Community Trust, where the Community Trust's contracting mechanisms are not well developed, or if the Community Trust managers are under-informed of pharmacy service requirements.

Why should pharmacy managers be concerned about activity within a Community Trust?

In the current environment, it is tempting for managers to concentrate on Acute Trust issues.

However strategic direction for the NHS as envisaged in 'Primary care - the future" illustrates the possible new ways in which services may be delivered. If pharmacy managers ignore the services needed within Community Trusts, they risk the Trusts moving forward in key therapeutic areas without effective pharmaceutical advice. Pharmaceutical Advisers have been very successful m developing their role within purchasing organisations, but they cannot substitute for in-house professional advice. There is a real risk that opportunities for the profession as a whole, including community pharmacy, will be lost. New developments which could be affected include innovative services within GP practices, specialised multidisciplinary community teams, hospital at home schemes, nurse prescribing, and services developed jointly with local authority social services departments. The case for utilising the skills of pharmacists in all branches of the profession may not then be advocated, and other professions will develop roles to which we aspire.

The way forward

Pharmacy managers face difficult choices in responding to a Community Trust's demands for autonomy while retaining the hard-won strengths of an integrated, district-wide pharmaceutical service. Local solutions may vary, but most will involve a degree of development of responsibility from the senior pharmacy manager to pharmacist(s) directly employed by a Community Trust. This has already happened in larger Community Trusts, without obvious detriment to the overall standard of service. Many hospital pharmacy managers have devoted their careers to developing a comprehensive and high quality service; this new situation requires that future responsibility for parts of this cherished achievement be devolved to others. The management skills required to effect this change process will be demanding, but it must be recognised as in the profession's long term interest for pharmacists to make a direct contribution within every NHS Trust.

Reference:

1. Primary Care - the future NHS Executive May 1996

Beth Taylor,
October 1996

Reproduced with permission.