Community pharmacy in a commissioning-led NHS:can pharmacy compete effectively?

Introduction – The commissioning of services has been a core responsibility of English Primary Care Trusts (PCTs) since 2002. Primary care organisations (PCOs) in Scotland, Wales and Northern Ireland have also increased their commissioning activities but with, arguably, less fervour than their English counterparts. The commissioning function of English PCTs has been reinforced by the introduction of new contractual frameworks across primary care – for medical services, dentistry and pharmacy. The new pharmaceutical services contract for England and Wales introduced an “enhanced” category of services, the provision of which is dependent on the commissioning decisions of local PCTs. As the NHS, most pertinently in England, continues its transformation from a provider to a commissioner of healthcare, the ability of pharmacy to compete effectively for funding is likely to become increasingly important. Method - After piloting, in August 2006 a self-completion postal questionnaire was sent to a random sample of practising community pharmacists, stratified for country and sex, within Great Britain (n=1998), with a follow-up to non-responders 4 weeks later. Data were analysed using SPSS (v12.0). A final response rate of 51% (n=1023/1998) was achieved. Within the section of the questionnaire relating to service provision, respondents were asked “do you believe that pharmacy will be able to compete effectively with other healthcare providers for access to additional funding to develop services that address a public health need identified by your local Primary Care Organisation (PCO), e.g. PCT/LHB etc.?”. Answers were recorded on a three-point scale; pharmacy “will”, “may”, or “will not” be able to compete effectively for funding. Results - The attitudes of pharmacists showed variation depending on the type of pharmacy they worked in (supermarket, multiple (outlets (n)=200), large chain (200>n>20), small chain (20=n>5), or independent (n=5)) (?2 test with p=0.001). Over a third of survey pharmacists working in small chains and independents (37% (n=21/57) and 33% (n=113/341) respectively) believed that pharmacy would not be able to compete effectively for funding compared to 23% (n=15/65) for supermarket pharmacists, 22% (n=21/97) for pharmacists employed by large chains and just 18% (n=62/353) for pharmacists employed most regularly in multiples. Furthermore, attitudes also varied between the countries of residence of respondents (?2 test with p<0.05). 27% (n=242/893) of pharmacists resident in England and Wales believed that pharmacy would not be able to compete compared to 16% (n=18/116) of pharmacists resident in Scotland. Conclusions – It would appear that community pharmacists believe that the larger pharmacy chains and supermarkets will occupy an advantageous position in terms of attracting finance to develop services. This could have notable implications for service provision across the sector. If corporate pharmacy chains were to monopolise commissioning monies then the proportion of funding available to independents will be diminished; arguably further hastening their demise, as well as stifling the professional development of pharmacists employed within the independent sector. These findings, when combined with the variation observed between UK pharmacists operating under different contractual frameworks, may be a reflection of the divergent policy in the different administrations with developments in England, including the new pharmacy contract, reflecting a market-based approach with Scotland taking a near opposite stance with service integration and a commitment to new public health. However, it should be acknowledged that the questionnaire did not allow for detection of ambiguities in, or misunderstandings of, the survey question and this should be considered as a limitation of the research.

The missing ingredient:inter-municipal cooperation and central-local relations in the UK

The thrust of the argument presented in this chapter is that inter-municipal cooperation (IMC) in the United Kingdom reflects local government's constitutional position and its exposure to the exigencies of Westminster (elected central government) and Whitehall (centre of the professional civil service that services central government). For the most part councils are without general powers of competence and are restricted in what they can do by Parliament. This suggests that the capacity for locally driven IMC is restricted and operates principally within a framework constructed by central government's policy objectives and legislation and the political expediencies of the governing political party. In practice, however, recent examples of IMC demonstrate that the practices are more complex than this initial analysis suggests. Central government may exert top-down pressures and impose hierarchical directives, but there are important countervailing forces. Constitutional changes in Scotland and Wales have shifted the locus of central- local relations away from Westminster and Whitehall. In England, the seeding of English government regional offices in 1994 has evolved into an important structural arrangement that encourages councils to work together. Within the local government community there is now widespread acknowledgement that to achieve the ambitious targets set by central government, councils are, by necessity, bound to cooperate and work with other agencies. In recent years, the fragmentation of public service delivery has affected the scope of IMC. Elected local government in the UK is now only one piece of a complex jigsaw of agencies that provides services to the public; whether it is with non-elected bodies, such as health authorities, public protection authorities (police and fire), voluntary nonprofit organisations or for-profit bodies, councils are expected to cooperate widely with agencies in their localities. Indeed, for projects such as regeneration and community renewal, councils may act as the coordinating agency but the success of such projects is measured by collaboration and partnership working (Davies 2002). To place these developments in context, IMC is an example of how, in spite of the fragmentation of traditional forms of government, councils work with other public service agencies and other councils through the medium of interagency partnerships, collaboration between organisations and a mixed economy of service providers. Such an analysis suggests that, following changes to the system of local government, contemporary forms of IMC are less dependent on vertical arrangements (top-down direction from central government) as they are replaced by horizontal modes (expansion of networks and partnership arrangements). Evidence suggests, however that central government continues to steer local authorities through the agency of inspectorates and regulatory bodies, and through policy initiatives, such as local strategic partnerships and local area agreements (Kelly 2006), thus questioning whether, in the case of UK local government, the shift from hierarchy to network and market solutions is less differentiated and transformation less complete than some literature suggests. Vertical or horizontal pressures may promote IMC, yet similar drivers may deter collaboration between local authorities. An example of negative vertical pressure was central government's change of the systems of local taxation during the 1980s. The new taxation regime replaced a tax on property with a tax on individual residency. Although the community charge lasted only a few years, it was a highpoint of the then Conservative government policy that encouraged councils to compete with each other on the basis of the level of local taxation. In practice, however, the complexity of local government funding in the UK rendered worthless any meaningful ambition of councils competing with each other, especially as central government granting to local authorities is predicated (however imperfectly) on at least notional equalisation between those areas with lower tax yields and the more prosperous locations. Horizontal pressures comprise factors such as planning decisions. Over the last quarter century, councils have competed on the granting of permission to out-of-town retail and leisure complexes, now recognised as detrimental to neighbouring authorities because economic forces prevail and local, independent shops are unable to compete with multiple companies. These examples illustrate tensions at the core of the UK polity of whether IMC is feasible when competition between local authorities heightened by local differences reduces opportunities for collaboration. An alternative perspective on IMC is to explore whether specific purposes or functions promote or restrict it. Whether in the principle areas of local government responsibilities relating to social welfare, development and maintenance of the local infrastructure or environmental matters, there are examples of IMC. But opportunities have diminished considerably as councils lost responsibility for services provision as a result of privatisation and transfer of powers to new government agencies or to central government. Over the last twenty years councils have lost their role in the provision of further-or higher-education, public transport and water/sewage. Councils have commissioning power but only a limited presence in providing housing needs, social care and waste management. In other words, as a result of central government policy, there are, in practice, currently far fewer opportunities for councils to cooperate. Since 1997, the New Labour government has promoted IMC through vertical drivers and the development; the operation of these policy initiatives is discussed following the framework of the editors. Current examples of IMC are notable for being driven by higher tiers of government, working with subordinate authorities in principal-agent relations. Collaboration between local authorities and intra-interand cross-sectoral partnerships are initiated by central government. In other words, IMC is shaped by hierarchical drivers from higher levels of government but, in practice, is locally varied and determined less by formula than by necessity and function. © 2007 Springer.

Reforming public services in the UK:Bringing in the third sector

In the UK, the government continues its project to reform public services. Earlier projects have focused on the modernization of public sector organizations; in the latest round of reform, New Labour has focused on widening choice and the personalization of services. To this end, the government has been working with Third Sector (TS) organizations to expand their role in shaping, commissioning and delivering public services. The government's vision is predicated on a normative assertion, that, unlike traditional public sector organizations, TS bodies create public value by being more innovative, are inspired by altruistic aims and values, and have greater commitment to their clients. This paper reviews recent policy and questions whether the government's policy is flawed, contradictory and risks damaging the attributes of the TS admired by New Labour. © 2007 The Author. Journal compilation © 2007 Blackwell Publishing Ltd.

The development and optimisation of a fast pyrolysis process for bio-oil production

A two-tier study is presented in this thesis. The first involves the commissioning of an extant but at the time, unproven bubbling fluidised bed fast pyrolysis unit. The unit was designed for an intended nominal throughput of 300 g/h of biomass. The unit came complete with solids separation, pyrolysis vapour quenching and oil collection systems. Modifications were carried out on various sections of the system including the reactor heating, quenching and liquid collection systems. The modifications allowed for fast pyrolysis experiments to be carried out at the appropriate temperatures. Bio-oil was generated using conventional biomass feedstocks including Willow, beechwood, Pine and Miscanthus. Results from this phase of the research showed however, that although the rig was capable of processing biomass to bio-oil, it was characterised by low mass balance closures and recurrent operational problems. The problems included blockages, poor reactor hydrodynamics and reduced organic liquid yields. The less than optimal performance of individual sections, particularly the feed and reactor systems of the rig, culminated in a poor overall performance of the system. The second phase of this research involved the redesign of two key components of the unit. An alternative feeding system was commissioned for the unit. The feed system included an off the shelf gravimetric system for accurate metering and efficient delivery of biomass. Similarly, a new bubbling fluidised bed reactor with an intended nominal throughput of 500g/h of biomass was designed and constructed. The design leveraged on experience from the initial commissioning phase with proven kinetic and hydrodynamic studies. These units were commissioned as part of the optimisation phase of the study. Also as part of this study, two varieties each, of previously unreported feedstocks namely Jatropha curcas and Moringa olifiera oil seed press cakes were characterised to determine their suitability as feedstocks for liquid fuel production via fast pyrolysis. Consequently, the feedstocks were used for the production of pyrolysis liquids. The quality of the pyrolysis liquids from the feedstocks were then investigated via a number of analytical techniques. The oils from the press cakes showed high levels of stability and reduced pH values. The improvements to the design of the fast pyrolysis unit led to higher mass balance closures and increased organic liquid yields. The maximum liquid yield obtained from the press cakes was from African Jatropha press cake at 66 wt% on a dry basis.

Phase equilibrium studies at moderate pressures

The theory of vapour-liquid equilibria is reviewed, as is the present status or prediction methods in this field. After discussion of the experimental methods available, development of a recirculating equilibrium still based on a previously successful design (the modified Raal, Code and Best still of O'Donnell and Jenkins) is described. This novel still is designed to work at pressures up to 35 bar and for the measurement of both isothermal and isobaric vapour-liquid equilibrium data. The equilibrium still was first commissioned by measuring the saturated vapour pressures of pure ethanol and cyclohexane in the temperature range 77-124°C and 80-142°C respectively. The data obtained were compared with available literature experimental values and with values derived from an extended form of the Antoine equation for which parameters were given in the literature. Commissioning continued with the study of the phase behaviour of mixtures of the two pure components as such mixtures are strongly non-ideal, showing azeotopic behaviour. Existing data did not exist above one atmosphere pressure. Isothermal measurements were made at 83.29°C and 106.54°C, whilst isobaric measurements were made at pressures of 1 bar, 3 bar and 5 bar respectively. The experimental vapour-liquid equilibrium data obtained are assessed by a standard literature method incorporating a themodynamic consistency test that minimises the errors in all the measured variables. This assessment showed that reasonable x-P-T data-sets had been measured, from which y-values could be deduced, but that the experimental y-values indicated the need for improvements in the design of the still. The final discussion sets out the improvements required and outlines how they might be attained.

Ablative pyrolysis of biomass

The primary objectives of this work were to design, construct, test and operate a novel ablative pyrolysis reactor and product recovery system. Other key objectives included the development of an ablative pyrolysis reactor design methodology, mathematical modelling of the ablation process and measurement of empirical ablation rate data at 500°C. The constructed reactor utilised a rotating blade approach to achieve particle ablation in a 258mm internal diameter reactor. By fulfilling the key requirements of high relative motion and high contact pressure, pine wood particles of maximum size 6.35 mm were successfully ablated.Sixteen experiments were carried out: five initial commissioning experiments were used to test the rotating blade concept and to solve char separation problems. Mass balances were obtained for the other eleven experiments with good closures. Based on ablatively pyrolysed dry wood, a maximum organic liquid yield of 65.9 wt% was achieved with corresponding yields of 12.4 wt% char, 11.5 wt% water and 9.2 wt% non-condensable gas. Reactor throughputs of 2 kg/h dry ablated wood were achieved at 600°C. The theoretical ablative pyrolysis reactor design methodology was simplified and improved based upon empirical data derived from wood rod ablation experiments. Yields of chemicals were qualitatively similar to those of other fast pyrolysis processes.The product recovery system, comprising hot char removal, liquids collection in two ice-cooled condensers followed by gas filtration and drying, gave good mass balance closures. The most significant problem was char separation and removal from the reactor. This was solved by using a nitrogen blow line. In general, the reactor and product collection systems performed well.Future development of the reactor would involve modification of the reactor feed tube to allow the reactor residence time to be reduced and testing of the rotating blade approach with different blade angles, configurations and numbers of blades.

Gasification of rubberwood in a downdraft gasifier

The objectives of this research were to investigate the perforamnce of a rubberwood gasifier and engine with electricity generation and to identify opportunities for the implementation of such a system in Malaysia. The experimental work included the design, fabrication and commissioning of a throated downdraft gasifier in Malaysia. The gasifier was subsequently used to investigate the effect of moisture content, dry wood capacity and particle size of rubberwood on gasifier performance. Additional experiments were also conducted to investigate the influence of two different nozzle numbers and two different throat diameters on tar cracking. A total of 101 runs were completed during the duration of the research. From the experimental data, the average mass balance was found to be 92.65%. The average energy balance over the gasifier to hot raw gas was 98.7%, to cold clean gas was 102.4% and over the complete system was 101.9%. The heat loss from the gasifier was estimated to range from 10-26% of the chemical energy of the feedstock. From the downstream operation, the heat loss was estimated to range from 17-37% of the chemical energy of rubberwood feedstock. The maximum throughput for stable operation was found to be 60-70% of the maximum dry wood capacity. The gasifier was found to have a maximum turndown ratio of 5:1. It is also postulated that the phenomenon of turndown of the gasifier is due to a `bubble theory' occurring at the gasification zone, and this hypothesis is explained. For stable power output, the working range of the engine was found to be 5-33.5 kWe. The thermal efficiency and diesel displacement of the engine was found to be 17-18% and 65-70% respectively. The research also showed that rubberwood gasification in Malaysia is feasible if the price of diesel is above MR35/l and the price of wood is below MR120/tonne.

Gasification of biomass in a downdraft reactor

The objective of this study was to design, construct, commission and operate a laboratory scale gasifier system that could be used to investigate the parameters that influence the gasification process. The gasifier is of the open-core variety and is fabricated from 7.5 cm bore quartz glass tubing. Gas cleaning is by a centrifugal contacting scrubber, with the product gas being flared. The system employs an on-line dedicated gas analysis system, monitoring the levels of H2, CO, CO2 and CH4 in the product gas. The gas composition data, as well as the gas flowrate, temperatures throughout the system and pressure data is recorded using a BBC microcomputer based data-logging system. Ten runs have been performed using the system of which six were predominantly commissioning runs. The main emphasis in the commissioning runs was placed on the gas clean-up, the product gas cleaning and the reactor bed temperature measurement. The reaction was observed to occur in a narrow band, of about 3 to 5 particle diameters thick. Initially the fuel was pyrolysed, with the volatiles produced being combusted and providing the energy to drive the process, and then the char product was gasified by reaction with the pyrolysis gases. Normally, the gasifier is operated with reaction zone supported on a bed of char, although it has been operated for short periods without a char bed. At steady state the depth of char remains constant, but by adjusting the air inlet rate it has been shown that the depth of char can be increased or decreased. It has been shown that increasing the depth of the char bed effects some improvement in the product gas quality.

The microbiological destruction of thiocyanate in activated sludge plants treating coke oven effluent

The treatment of effluents produced during the manufacture of metallurgical coke is normally carried out using the activated sludge process. The efficiency of activated sludges in purifying coke oven effluent depends largely on the maintenance of species of micro-organisms which destroy thiocyanate. The composition, production, toxicity and treatment of coke oven effluent at Corby steelworks are described. A review is presented which follows the progress made towards identifying and monitoring the species of bacteria which destroy thiocyanate in biological treatment plants purifying coke oven effluents. In the present study a search for bacteria capable of destroying thiocyanate led to the isolation of a species of bacteria, identified as Pseudomonas putida, which destroyed thiocyanate in the presence of succinate; this species had not previously been reported to use thiocyanate. Washed cell suspensions of P. putida destroyed phenol and thiocyanate simultaneously and thiocyanate destruction was not suppressed by pyridine, aniline or catechol at the highest concentrations normally encountered in coke oven effluent. The isolate has been included, as N.C.I.B. 11198, in the National Collection of Industrial Bacteria, Torrey Research Station, Aberdeen. Three other isolates, identified as Achromobacter sp., Thiobacillus thioparus and T. denitrificans, were also confirmed to destroy thi.ocyanate. A technique has been developed for monitoring populations of different species of bacteria in activated sludges. Application of this technique to laboratory scale and full scale treatment plants at Corby showed that thiobacilli were usually not detected; thiobacilli were el~inated during the commissioning period of the full scale plant. However experiments using a laboratory scale plant indicated that during a period of three weeks an increase in the numbers of thiobacilli might have contributed to an improvement in plant performance. Factors which might have facilitated the development of thiobacilli are discussed. Large numbers of fluorescent pseudomonads capable of using thiocyanate were sometimes detected in the laboratory scale plant. The possibility is considered that catechol or other organic compounds in the feed-liquor might have stimulated fluorescent pseudmonads. Experiments using the laboratory scale plant confirmed that deteriorations in the efficiency of thiocyanate destruction were sometimes caused by bulking sludges, due to the excessive growth of fungal floes. Increased dilution of the coke oven effluent was a successful remedy to this difficulty. The optimum operating conditions recommended by the manufacturer of the full scale activated sludge plant at Corby are assessed and the role of bacterial monitoring in a programme of regular monitoring tests is discussed in relation to the operation of activated sludge plants treating coke oven effluents.

The development of a testing procedure for dry friction brakes

A description of the background to testing friction materials for automotive brakes explains the need for a rapid, inexpensive means of assessing their behaviour in a way which is both accurate and meaningful. Various methods of controlling inertia dynamometers to simulate road vehicles are rejected in favour of programming by means of a commercially available XY plotter. Investigation of brake service conditions is used to set up test schedules, and a dynamometer programming unit built to enable service conditions on vehicles to be simulated on a full scale dynamometer. A technique is developed by which accelerated testing can be achieved without operating under overload conditions, saving time and cost without sacrificing validity. The development of programming by XY plotter is described, with a method of operating one XY plotter to programme the machine, monitor its own behaviour, and plot its own results in logical sequence. Commissioning trials are described and the generation of reproducible results in frictional behaviour and material durability is discussed. Teclmiques are developed to cross check the operation of the machine in retrospect, and retrospectively correct results in the event of malfunctions. Sensitivity errors in the measuring circuits are displayed between calibrations, whilst leaving the recorded results almost unaffected by error. Typical results of brake lining tests are used to demonstrate the range of performance parameters which can be studied by use of the machine. Successful test investigations completed on the machine are reported, including comments on behaviour of cast iron drums and discs. The machine shows that materials can repeat their complex friction/ temperature/speed/pressure relationships at a reproducibility of the order of +-0.003u and +~ 0.0002 in. thickness loss during wear tests. Discussion of practical and academic implications completes the report with recommendations for further work in both fields.

Obstacles and solutions to maximising biodiversity in major urban development schemes

The current rate of global biodiversity loss led many governments to sign the international agreement ‘Halting Biodiversity Loss by 2010 and beyond’ in 2001. The UK government was one of these and has a number of methods to tackle this, such as: commissioning specific technical guidance and supporting the UK Biodiversity Acton Plan (BAP) targets. However, by far the most effective influence the government has upon current biodiversity levels is through the town planning system. This is due to the control it has over all phases of a new development scheme’s lifecycle.There is an increasing myriad of regulations, policies and legislation, which deal with biodiversity protection and enhancement across the hierarchical spectrum: from the global and European level, down to regional and local levels. With these drivers in place, coupled with the promotion of benefits and incentives, increasing biodiversity value ought to be an achievable goal on most, if not all development sites. However, in the professional world, this is not the case due to a number of obstructions. Many of these tend to be ‘process’ barriers, which are particularly prevalent with ‘urban’ and ‘major’ development schemes, and is where the focus of this research paper lies.The paper summarises and discusses the results of a questionnaire survey, regarding obstacles to maximising biodiversity enhancements on major urban development schemes. The questionnaire was completed by Local Government Ecologists in England. The paper additionally refers to insights from previous action research, specialist interviews, and case studies, to reveal the key process obstacles.Solutions to these obstacles are then alluded to and recommendations are made within the discussion.

GPs' perspectives on managing the NHS Health Check in primary care:a qualitative evaluation of implementation in one area of England

OBJECTIVES: To evaluate the implementation of the National Health Service (NHS) Health Check programme in one area of England from the perspective of general practitioners (GPs). DESIGN: A qualitative exploratory study was conducted with GPs and other healthcare professionals involved in delivering the NHS Health Check and with patients. This paper reports the experience of GPs and focuses on the management of the Heath Check programme in primary care. SETTING: Primary care surgeries in the Heart of Birmingham region (now under the auspices of the Birmingham Cross City Clinical Commissioning Group) were invited to take part in the larger scale evaluation. This study focuses on a subset of those surgeries whose GPs were willing to participate. PARTICIPANTS: 9 GPs from different practices volunteered. GPs served an ethnically diverse region with areas of socioeconomic deprivation. Ethnicities of participant GPs included South Asian, South Asian British, white, black British and Chinese. METHODS: Individual semistructured interviews were conducted with GPs face to face or via telephone. Thematic analysis was used to analyse verbatim transcripts. RESULTS: Themes were generated which represent GPs' experiences of managing the NHS Health Check: primary care as a commercial enterprise; 'buy in' to concordance in preventive healthcare; following protocol and support provision. These themes represent the key issues raised by GPs. They reveal variability in the implementation of NHS Health Checks. GPs also need support in allocating resources to the Health Check including training on how to conduct checks in a concordant (or collaborative) way. CONCLUSIONS: The variability observed in this small-scale evaluation corroborates existing findings suggesting a need for more standardisation. Further large-scale research is needed to determine how that could be achieved. Work needs to be done to further develop a concordant approach to lifestyle advice which involves tailored individual goal setting rather than a paternalistic advice-giving model.