OPINION


Looking back at


VISION 2020


GeORGe ORWeLL AND sTANLeY KuBRICK WeRe NeVeR eXPOseD TO THIs RIsK OF HuMILIATION. WHeN 1984 ARRIVeD, THe AuTHOR WAs LONG DeAD AND, WHeN 2001 DAWNeD, KuBRICK THe FILMMAKeR WAs FIRMLY IN THe HeAVeNs. NO ONe WAs sCRuTINIsING AND COMPARING THeIR FICTIONAL VIsIONs WITH THe ReALITY.


By Dr Terry Maguire I


authored Vision 2020 in the late 1990s and now that 2020 is here, some - assuming they are still alive -


may ask if ‘the Vision’ has become reality? Did Vision 2020 have an impact on the development of community pharmacy practice in Northern Ireland?


In 1998, the Pharmaceutical society of Northern Ireland (PsNI) finally agreed Vision 2020 as its vision for the future of community pharmacy. It had been a long slog as there were important and influential dissenting voices. At that time - and perhaps today still - I find difficulty seeing the real concerns…the true agendas behind the fake excuses. They were there then and they still are.


In 1995, I started work on Vision 2020 because it was my view that real risks existed if pharmacy failed to adopt a clinical future. supply services needed to change to clinical services or we risked having no future.


Pharmaceutical care, as defined by Charles Hepler and Linda strand in the early 1990s, was the inspiration for, and the main thrust of, Vision 2020 as it offered the necessary change and sustainability for community pharmacy. But Hepler and strand’s definition was, for me at least, too restrictive. It did not consider how pharmacists might make an impact on public health and improve self-care.


I actually had a number of frank discussions with Charles Hepler who, while always polite, found my argument on the limitations of pharmaceutical care somewhat irritating. Indeed, during one


30 - PHARMACY IN FOCus


discussion, he stated that I clearly misunderstood the fundamental essence of the idea.


Pharmaceutical care is not care by pharmacists, rather it is care by pharmaceuticals (medicines, drugs) and I was fully aware of this. I was, however, also aware that we needed something wider than this to transform the service that our 500 pharmacies provided to their patients and communities.


In additional to pharmaceuticals, I also added public health and self- care, speculating on community pharmacy’s potential contribution to changing behaviours that impacted on health and wellbeing: smoking, alcohol, nutrition and exercise. Vision 2020 boiled down to three domains: pharmaceutical care, self-care and public health. Of course, these domains were not distinct and mutually exclusive; there is significant overlap. For example, the smoker collecting her inhaler to treat her COPD needs more than advice on proper inhaler technique; the pharmacist needs to consider smoking and how she might be supported to stop.


Vision 2020 was essentially a bold statement of what PsNI saw as the roles and responsibilities of community pharmacists twenty years into the future. By making this statement, it was hoped that we would choose the right policies and create a momentum that would eventually make the vision a reality and to do so by the year 2020. Now that 2020 is here - and I must confess it has come much too fast – how successful has the Vision been and has it brought us to sunlit uplands?


It’s been a mixed bag. some things have been successful, others have not


and some have been delivered, albeit not successfully.


using Vision 2020, the Department of Health (DoH) published its policy for community pharmacy - ‘Making It Better’ - a few years into the new millennium. sadly, discussions between DoH and the pharmacy negotiating body, now Community Pharmacy Northern Ireland (CPNI), hit a wall very early on. Negotiators wanted all new commissioned activity - the clinical and public health services - to be paid as additional to the existing funding pot. DoH argued that it was a transition where there would be some new money but that, ultimately, it was necessary for fees for supplying medicines to be reduced in order to expand and fund new services. The next twenty years were a negotiating disaster. CPNI stalled where it could and DoH aggressively reduced funding, nearly bankrupting contractors.


CPNI took three Judicial Reviews, ultimately losing in the end and paying a hefty legal bill. DoH got to such a point of frustration that CPNI was almost being ignored when, finally, in November 2018, a new contract was imposed and all the fighting just seemed to stop. The absence of a contract was causing considerable financial hardship and something had to give. Most contractors were happy to take what was on offer and see a way out of their hefty overdrafts.


The new contract is now commissioning services across the three domains. Living Well is a public health service that supports pharmacists in engaging in brief interventions on exercise, care in the sun, nutrition and smoking. The


smoking cessation service was a big win early on. The flagship of pharmacy public health is Health+ Pharmacy, but, sadly, this impressive scheme has run aground as contractors won’t agree to some of the standards, such as a restriction on selling confectionery, e-cigs and low factor sunscreen. The minor ailments service, which is designed to keep patients out of GP practices and A&e is part of Pharmacy First and is currently allowing us to treat patients with cold and flu symptoms on the health service.


Pharmaceutical care, now called medicines optimisation, has been less successful for community pharmacy, but has ensured a practice pharmacist in every GP surgery. Apart from the loss of investment in community pharmacy, it also triggered a major workforce crisis as 450 pharmacists took jobs that are 9 to 5 and come with a decent pension. (In my world, a day off at short notice would be nice!)


Vision 2020 may have had an impact, but perhaps things were moving this way anyway and we would have ended up here without it. Contractors did not buy into Vision 2020 as I would have wished and seemed too focused on issue such as monitored dosage systems, free prescription collection and delivery and investing in robotics. so, to say clinical services are now a part of the community pharmacist’s role is wrong.


The dangers I saw back in the 1990s remain a problem for the sustainability of the network. Like uK society in 1984 - and space in 2001 - community pharmacy in 2020 is certainly not what was envisioned.


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