Health and Social Care Committee
Oral evidence: Pharmacy, HC 140
Tuesday 16 January 2024
Ordered by the House of Commons to be published on 16 January 2024.
Members present: Steve Brine (Chair); Paul Blomfield; Mrs Paulette Hamilton; Rachael Maskell; James Morris.
Questions 59 - 122
Witnesses
I: Deborah Evans, Clinic Director and Superintendent Pharmacist, Remedi Health; and William Pett, Head of Policy, Public Affairs and Research, Healthwatch England.
II: Mark Koziol, Chairman, Pharmacists’ Defence Association; Duncan Rudkin, Chief Executive and Registrar, General Pharmaceutical Council; and Nicola Stockmann, Vice President, Association of Pharmacy Technicians UK.
Witnesses: Deborah Evans and William Pett.
Q59 Chair: Good morning. This is the Health and Social Care Committee. We are live from the Palace of Westminster in London. This is the second public evidence session of our pharmacy inquiry. We are looking at the future of pharmacy, both community pharmacy and hospital pharmacy.
With our first panel this morning, we are going to look at innovation in the delivery of pharmacy services, and patient understanding and wishes for the future, based on their experiences of working with the sector and the public. We will then take a short break. With panel 2, which will come afterwards, we will look at workforce, to understand what a pharmacy technician of the future might look like. The additional roles are a rather live issue in pharmacy at the moment.
Let me introduce those we have before us this morning. William Pett is the head of policy for public affairs and research at Healthwatch England. It is nice to see you, Mr Pett. Deborah Evans is the clinic director and superintendent pharmacist at Remedi Health. I should declare my interest, for full disclosure. Deborah is a practising pharmacist in Winchester, the constituency that I represent in the House of Commons.
I am going to kick off and I will then bring in my colleague Paulette Hamilton. I have said something about the inquiry that we are holding and the reason that we are holding it. We have the son of a pharmacist in No. 10, who still lives above the shop. He grew up above one not far from my constituency, in Southampton. If ever it was going to work, you would think that it would be now. There is great potential in pharmacy. We hear this all the time. “We want pharmacists to do more,” Ministers say—I used to say it when I was the pharmacy Minister—and they are doing more. What we are interested in is, where are the limitations of that, if there are any, and what does the future of pharmacy look like? Let’s start with you, Deborah. What does the future of pharmacy look like, other than your store in Winchester?
Deborah Evans: I am passionate about the profession and what the sector can deliver for patients and the public. I am fairly reserved about what the future can look like. Potentially, the future is enormous. I will talk about the practice that I operate, but I do not have an NHS practice. I have a private practice.
Q60 Chair: Why don’t you just give us a sense of what Remedi Health is and what it offers?
Deborah Evans: I opened Remedi Health two years ago as a clinic and pharmacy. It switches the model around. Patients and the public come into my premises and practice for health solutions. They have issues. They cannot get into their GP. They are worried about their health or just want to check in around their health. I am able to offer them a very wide range of services that they pay for. Medicines are, or could be, part of the solution.
To give you a feel for the kinds of services that Remedi Health delivers, we can be a walk-in for primary care services, not dissimilar to Pharmacy First, but it goes beyond that. We offer a full contraception service. I have recently been accredited as a Faculty of Sexual and Reproductive Health implant fitter and remover. I am a menopause specialist, so I run a menopause clinic. We offer a full blood screening service and phlebotomy and a full vaccine service. We offer health checks and cancer screens. I offer pharmacogenomic and DNA testing. We offer a travel service and weight management, with full back-up and support. Of course, there are the usual things that you would expect to find in a pharmacy, such as blood pressure checks, cholesterol health checks and other public health services. We are also able to provide sexual health screening.
I am sure I’ve missed out a number of other things, but the key part of what I deliver with my team is that I am a prescribing pharmacist. We are able to give an end-to-end solution, from people walking in, through diagnostics, to solutions. We have a big referral network to tertiary care, if we need it, whether that be within the NHS or outwith the NHS. We can refer for DEXA scans, MRIs, ultrasounds and CT. If you are a patient or member of the public walking into Remedi Health, you are able to get support and care that will help you to navigate through the system, whether that is back into the NHS or not.
What I am able to say about the model in particular, and the possible limitations with community pharmacy as it sits at the moment, is that what I am able to provide for patients and clients is time. The minimum amount of time that I spend with a client is half an hour. We have full support from a very capable and qualified team. The whole process is underpinned by a consultation, which can then result in a prescription. That is a little bit about what we do.
Q61 Chair: Obviously, your prescribing volumes are lower than those of a regular NHS-contracted community pharmacy. Is there a lesson in that? In the first session of this inquiry, we considered a hub-and-spoke model and its potential, and it really is only that, because we have no response from the Government as to what their hub-and-spoke intentions are. Does that point to the future? Independent Community Pharmacist magazine said that you were reversing “the traditional community pharmacy approach”. Is that because you are not dealing with big volumes?
Deborah Evans: Absolutely. My team and I could not deliver what we deliver if we were delivering NHS prescriptions. It is an active choice not to take an NHS contract, for that very reason.
Q62 Chair: Okay. Mr Pett, Healthwatch England said that there is “some hesitancy about visiting a pharmacy before seeing a GP” and that people were “not always clear” about the roles and expertise of pharmacy staff and were often “unsure whether they were talking to a pharmacist or shop assistant and what each can…do for them”. Can you expand that? As you do so, can you talk about the barriers to entering a pharmacy, private or public?
William Pett: Good morning, Chair and members of the Committee. Thank you very much for having us. Healthwatch England is very grateful to have the opportunity to put forward the patient view on this really important area of care.
Let me start with some positives. First, pharmacy is a highly valued local service for many people across the country. Pharmacy is regularly used. The average person uses a pharmacy about 14 times per year. Generally, trust in pharmacists is really high among members of the public. People trust them to give good-quality care and advice.
There are some really severe challenges facing the pharmacy sector that we need to emphasise. Today I am hoping to talk through three Cs that Healthwatch England has identified as some of the biggest challenges facing the sector. The first of those Cs is confidence. Confidence in pharmacy services is being eroded, primarily by medicine shortages, staffing issues and closures.
The second C is culture. We must accept that many patients are used to seeing their GP as their first port of call for many health conditions. Pharmacy First is welcome, but there are going to be some restrictions on how quickly some patients will want to take up some of those services, rather than seeing their GP.
Q63 Chair: Because they think of GP first, not Pharmacy First.
William Pett: Yes. I am happy to talk through some of the detail of that hesitancy this morning. We have some stats on that.
Before I do, the third C is cost of living. Cost of living pressures are not in the headlines as much as they were in previous years, but cost of living is a huge barrier to many members of the public taking up pharmacy services. Unless action is taken on that, we will continue to see people avoiding pharmacy for that reason. Would you like me to talk a bit more about the hesitancy in using pharmacy services?
Q64 Chair: I would like you to reflect a bit more on the cost of living point. Expand on that. A lot of services that you find in a community pharmacy are free, much to their chagrin. There is no reimbursement for a lot of those services and the over-the-counter advice. That is why people trust and have confidence—your first C. Of course, that is not a cost of living issue because people are not paying for it.
William Pett: Ninety per cent. of medications are dispensed for free, which is positive. However, we know that many low-income individuals have real problems affording medication—those who are not on state benefits and are not exempt from prescription charges. We have done research on that. We did cost of living research last year, which revealed that one in 10 people had avoided taking up one or more prescriptions because of prohibitive cost, being unable to afford the prescription charges. One in 10 had avoided buying over-the-counter medicine, again because of the cost. Allow me to put it into a human context with a story from one patient we heard from. One father of three, who works full time but does not have enough money for basic necessities, could not afford the prescribed medication for chronic acid reflux, so he lives with constant stomach pain. He said to us, “I’d rather spend my money on food for my kids.”
Essentially, we need to do more to address those issues. We urge that the exemption categories be looked at. More specifically, the Government need to do more to raise awareness of mechanisms that help people to afford medication. For example, the prescription pre-payment certificates help low-income individuals to afford multiple prescriptions over a period of time. There is really low awareness of those certificates. An estimated 1 million people who could benefit from the certificates currently do not. That is due largely to lack of awareness. There are other measures that we would urge. We urge consideration of reintroducing an NHS minor ailments scheme, which essentially allows pharmacists to prescribe over-the-counter medication for free to those who are exempt from prescription charges.
Q65 Chair: To go back to hesitancy and the mindset of GP first, not Pharmacy First, unpack that. What is that hesitancy built around?
William Pett: I am happy to. First, on Pharmacy First services specifically, Healthwatch England has been doing research into Pharmacy First and attitudes towards pharmacy more broadly. We will publish our full findings in March, but let me trail some of the poll findings that we found in November last year.
We asked about seven conditions. We found that, while the public were generally positive about going to pharmacy for things like sore throats and earache—generally, there were high levels of likelihood that patients would go to pharmacies for those conditions—that was far less the case for UTIs and shingles.
When we got into why that is, we found that, first, there is an awareness point. The public need to be aware that those services are offered by pharmacy, so we urge public awareness-raising when Pharmacy First is launched nationally. There are three issues that play into that. First, we heard that one of the top reasons why people were unlikely to go to pharmacy for those two conditions was that they just prefer seeing their GP. We heard from patients that a lot of that was around continuity. Patients are likely to have seen their GP and to have built a relationship with them over several years.
There were other factors. Privacy is a really important concern for some patients, especially on sensitive issues like UTIs. Patients want to know that they are going to be seen privately, in a consultation room. Many patients are not aware that pharmacy offers private consultation rooms, or do not have much faith in the privacy that those consultation rooms offer.
The third one is really important. Patients do not want to be bounced around services. There is safety in going to see your GP and knowing that you will get treatment through them. For the Pharmacy First conditions, if it is a more serious condition, you will be referred back to general practice. For a lot of patients, that could be a real frustration. If you go to your GP, you know that you will probably get treatment. We need to build confidence among the public that, if you go to your pharmacist, you will be able to get seen for that condition without being referred back to your GP.
Q66 Chair: Deborah, what are your thoughts on the launch, or relaunch, of Pharmacy First, which is coming shortly? How do you think that will impact on the model that you operate?
Deborah Evans: I don’t think that it will impact on my model in terms of the patients and clients who come into the pharmacy. From a sector point of view, it is an incredibly exciting and welcome development in the role that pharmacy can play. My experience of the public’s perception of pharmacy is that it is changing. I do not have any data around it, but that is from the conversations I have with people.
The biggest issue for the sector will be around capacity to deliver the service. We know from the closures that have happened in community pharmacy that those that are still operating are having to do more. They are doing more with less, because of the funding model, which is not sufficient to support the sector. There is an issue around capacity and around capability, giving pharmacists the time and space to be able to develop. From talking to colleagues, I think that the sector is essentially on its knees. Therefore, it is about being able to find the head space to be able do the training to get to the point where you are ready to deliver the service.
A cultural change will be needed within community pharmacy. This is a change management process. It is not enough to write a service specification and expect it to be delivered. There is much work to be done. We only have to look to our colleagues in Scotland and the work that they put behind enabling pharmacists to get to the point where they are able to deliver their Pharmacy First, which took years to put in place, not a month or so.
There are some real challenges for the sector. It is a fantastic opportunity to use our clinical skills. I feel very confident that pharmacists will be able to do that, once they have undertaken the training, but I go back to my consultation model. We spend a lot of time with our patients, and in making sure that the practice is safe and underpinned by the appropriate clinical governance. That requires time, which is something the sector does not have at the moment. There is already a backlog of days, if not longer, in prescription delivery. It comes back to your point, Chair, around the potential to take prescriptions out of the high-street model, to enable it to be a centre for clinical primary care.
Q67 Chair: Your model is interesting, and your evidence is timely, because if you are right, and I think you probably are, about Pharmacy First leading to a capacity issue for NHS-contracted community pharmacies, your model will only be more in demand. When you talk to patients, what are the reasons they give for coming your way? In primary care, there has been a big growth in self-pay. Young people, in particular—18 to 24 is the biggest bracket—are opting out of NHS general practice and paying online private GP services. They pay a monthly fee to have access to GP services. It is a stat that those in that age group are the ones who are increasingly doing that. When you talk to your customers, is it because some of the three Cs are playing out with them in terms of accessing public community pharmacy?
Deborah Evans: A lot of my clients are not necessarily the wealthy of Winchester choosing to access a private service, although we do have that clientele. Increasingly, we see people who are desperate to get a health solution and are willing to pay for it.
I will give you a couple of examples that immediately come to mind. A student nurse contacted us because she had done an NHS postal SDI kit and was positive for chlamydia. She contacted her GP to get antibiotic treatment. Her GP said, “We don’t do that. You have to go to the sexual health clinic.” She was then unable to access the sexual health clinic because it did not have the capacity to deal with her. In desperation, because she wanted to get treated, she came to us.
That is story No. 1. Story No. 2 is about a 72-year-old gentleman. He was concerned about prostate cancer. His brother had recently been diagnosed. He asked a GP if he could have a blood test to check his PSA and was told that the wait was two months, so he came to us. We tested him on the same day as his inquiry. We got the result back that night. It flagged up an issue, and he saw the urologist the next day. He would still have been waiting. That is two months. I am sure that those two months would be critical in his overall outcome.
It is the frustration with not being able to access primary care across the board. This is not about finding a solution in just one part of primary care. It is about joining it up and making sure that the whole thing works together.
Chair: You are right to bring pharmacy into primary care, because it is primary care; it’s pre-primary care. That is a very good start.
Q68 Mrs Hamilton: I am going to follow on from that. From some of the things that you are doing at the moment, are there two or three that you could say were quite scalable? Are there things that you could scale up so that we could use them quite successfully in NHS pharmacies? What you are talking about is actually quite expensive.
Deborah Evans: We have some things in place already. The contraception service, which is an NHS service, is available. It is about raising awareness of that contraception service. That is something that is already in place but needs more work to scale it up to get the engagement. Contraception is one example, for sure.
There is primary care support around the self-limiting, to some extent, but treatable conditions we have talked about. William made a point around minor ailments, where we have a lot of OTC solutions but people are unable to buy them. We have lots of successful examples of that around the country, where it has been locally commissioned.
Blood screening is something we do a lot of. We do a lot of blood tests. There is a real capacity issue in local blood services. I think that linking into ICBs, for example, for locally commissioned services is scalable.
Q69 Mrs Hamilton: My last question for Deborah, before I go across to William, is about finances. In some of the areas that I represent, I can assure you that they could not afford your services. Do you have a payment plan? You say that some of the people in Winchester are not wealthy, or what have you, but I will give you a simple example. I needed some vaccinations to go to Africa and I went to a pharmacist. It cost me nearly £200. I had the private consultant—everything you talked about. It was excellent, but it cost money. The point that I am trying to make to you is, if people don’t have that money, is there any way they could access a service that you offer through a payment plan? I cannot think of another way to put it.
Deborah Evans: I guess the situation would be where I was locally commissioned as a private provider by the service. I cannot run a business doing something for nothing. You must have the appropriate remuneration and reimbursement for whatever it is that you are delivering. It would have to be a locally commissioned process, I imagine. People who have private healthcare use our services; where they have paid into an insurance plan, they can get reimbursed from their private insurance company.
Q70 Mrs Hamilton: What worries me is that a two-tier system is developing. That is worrying. Thank you for that. It is really helpful.
William, over to you. I have a real bee in my bonnet about the fact that many GP surgeries have pharmacists attached to them. Those pharmacy practices are not always the best practices in the area to deliver the services that are needed, but because they have made deals and done it privately they tend to get the flow of all the patients from that particular practice. That is what happens unless you ask for something slightly different.
The point that I am trying to make is that sometimes you have other practices around the area, less than 30 yards away, that do not get that flow because they are not connected to the GP. When you were doing your report or any work in that area, what were your findings? Are pharmacists positioned in the right places to deliver the care that is needed for the area?
William Pett: The Government like to promote the fact that 80% of people live within a 20-minute walk of their local pharmacy, but being able to walk is itself a problem for a lot of people.
To your point about pharmacies attached to GPs, we do not have any data on quality or patients’ experience of those types of pharmacies versus others, but we would be supportive of the convenience to patients of having to go to your GP for one thing and being able to go to your pharmacist next door for treatment.
We have found that in recent years closures are causing huge access issues for patients. We are now at the lowest number of pharmacies across the country since 2016. We are particularly concerned about the fact that four in 10 closures in the last 10 or so years have been in the top 20% most deprived parts of the country. People are seeing real problems in just being able to get to their local pharmacy.
On closures, we need to distinguish between the permanent closures that we have seen—high-profile cases of Boots and Lloyds closing branches over the last year—and temporary closures, which are often not focused on as much as permanent closures but cause real issues for certain patients. We have had to rely on FOI data to try to reveal the scale of the problem. The data that we have shows that in 2021-22 there were 20,000 incidents of temporary closures across the country. There is regional variation; it is particularly high in Yorkshire and the north-east.
Q71 Chair: Can you define “temporary” for us? How long is it?
William Pett: Often we are talking about just a few hours in the afternoon. That is often due to staffing problems, with pharmacies not being able to support or source locums to help to keep the pharmacy running. That means that patients will go to the pharmacy to pick up a medication and find that there is a sign on the door saying, “Temporary closure.”
Q72 Chair: Interesting.
William Pett: Can I give you an example of what it means in terms of closures? Healthwatch Richmond did a really interesting piece of work recently that focused on the permanent closures of two Boots stores in a local area, which put huge pressure on a third branch. What that meant in practice for patients was that some people were left queuing outside in poor weather for up to an hour to pick up medication. They included pensioners with osteoarthritis, parents with sick children and elderly people picking up medication for an end of life patient. One diabetic had to go without their medication for two weeks. Closures across the country are causing huge issues, and they disproportionately affect people who struggle to get to their local pharmacy. That is a flavour of some of the research that we have done. I hope that is helpful.
Q73 Mrs Hamilton: That is really helpful. This is my very last point to you, because there are a number of other people wanting to ask questions. It relates to what you have just said. It is not necessarily about closures. Closures are a big issue—I am absolutely aware of that—but what I am more concerned about is the talent in the pharmacies. It varies quite a bit.
When you go into some pharmacies, you have a Rolls-Royce service. Perhaps you have to pay for it, but it is there. Some pharmacists do not even have time to distribute the medication that they have to do because they are so busy. You go through a hatch. At my pharmacist, at one point, you could not even go into the shop. That is why I changed my pharmacist. It was a hatch. They came to the door and asked you, “Is it a prescription?” Do you know what I mean? The service was so poor that, even if you wanted to speak to somebody, that was not there for you. How is that policed? A nurse has an NHS number and an NMC number. A doctor has to be registered. How do we police how those services are run and the quality of the services that are there?
William Pett: On quality, the first thing to say from a patient perspective is that national polling shows that, when people get to see a pharmacist, generally their experience of care is pretty good. The public perceptions polling that was done by Ipsos a couple of years ago showed that, when people see a pharmacist, around nine in 10 of them are happy with the quality of care that they receive from the pharmacist. That is positive.
What you are talking about is the frustration around pharmacists and their staff being overworked across the country. We know that full-time pharmacist levels across the country are falling. Last year they fell by 6%. Patients are sympathetic to overworked staff but are really frustrated about the knock-on impacts. To give you an idea of what that includes, unanswered phones cause massive problems for patients—just being able to get through to a pharmacist to find out what services they offer or, indeed, whether they have a medication in stock. We have talked about medication shortages. Patients are having to phone around pharmacists to try to work out where they can get their medication, but nobody answers the phone because the pharmacist is so overworked. Long queues and not being told when their prescription is ready are the kinds of issues that staffing problems are causing for patients.
Mrs Hamilton: I am going to leave it there. Others will go into it more deeply.
Q74 Chair: Thanks, Paulette. That was a very good exchange. Presumably, when you talk about unanswered phones, you mean the independents—the smaller single handers. If you get a prescription from Boots, you get a text message, and then a reminder text message, and then probably another one.
William Pett: Yes. I’m not sure of the distinction. When we hear from patients about problems getting through on the phone, we don’t have the data on which types of pharmacies we are talking about in particular, but it is a common problem that we hear about across the country. Patients find real frustration in not being able to get in touch with their pharmacist in advance.
Often, what happens is that a patient will not hear from their local pharmacy for a week about their prescription, so they go into the pharmacy to try to pick up their medication, only to find that it is either not ready or out of stock. If they were able to contact their pharmacy in advance over the phone, they would have been able to avoid that trip but many patients are not able to.
Q75 Chair: It is patchy though, isn’t it? It’s patchy and regional. I have heard stories of people getting a prescription or a text message from the pharmacist within the hour to say it is ready. It is different in different parts of the country. It is interesting that you talked about temporary closures. Is Yorkshire particularly bad?
William Pett: Particularly bad, yes.
Mrs Hamilton: Is there a big difference between living in a rural area and an inner-city area? Even though the pharmacists are in the inner city, I question the quality of some of the pharmacies. Do we have the same problems in a rural area because of staffing and distances? I need a little bit more information about that, but I think you want to move on, Chair.
Chair: Yes, let’s move on. We will draw it out as we go on.
Q76 Rachael Maskell: I want to ask about medicine shortages. This is an issue that we know is challenging for the profession and for patients. In light of the fact that technology is available—we keep hearing about the opportunities for technology—how can that address some of the issues around medicine shortages, particularly the point just made about patients having the onus of travelling? I had a constituent who went to seven pharmacies in order to get their prescription medication. What kind of solutions are there to address the availability of prescriptions?
William Pett: Shortages are obviously a topic that has hit the news in recent days. That absolutely reinforces our own research. To draw back to some of the polling we have done recently, we asked about shortages. One in four people across the country told us that they struggle to get prescriptions because of shortages. There are high-profile examples such as HRT and ADHD medication. There are stats that around 70% of ADHD patients have had to ration their medication as a result of shortages. There are other treatments as well that have been affected, such as painkillers, antibiotics and diabetes medication.
What we are concerned about, first, are the medical implications for patients who are rationing. We heard from one diabetic that they had to halve their dose because of shortages. More broadly, we are concerned about the practical consequences of shortages in the rigmarole that patients have to go through to get their medication. If they are not going back to their GP to ask for an alternative prescription, they are having to phone around multiple pharmacies, if they can get through. They have to rely on posting desperate messages on local Facebook groups to try to find out from other people in the area which pharmacy is stocking the medications, or they have to play what we call pharmacy bingo by physically traipsing around multiple different pharmacies, going in and asking, “Do you have this in stock?”
Wouldn’t it be fantastic if, in this day and age, patients were able to go online to some kind of database to see where pharmacies were stocking medication? It is the kind of thing that you can do if you want to pick up a Hoover from Argos. It is not something you can do if you want to potentially get significant—
Q77 Chair: There are a lot more pharmacy sites than there are Argos stores.
William Pett: Absolutely. I say it with a high degree of optimism. Of course, I understand the practical implications and challenges of trying to come up with some database that spans the stock of multiple different legal entities. I appreciate that it is not easy, but at the moment, in the 21st century when we have all sorts of technology, we have a system where patients are having to do the basic, arduous task of going round, when the information should be available much more easily. Something has to be done to improve that process because it is not working at the moment.
Q78 Rachael Maskell: Thank you. I want to come back to a written question that I asked the Minister regarding reconstituting the Department’s medicine supply team. You mentioned ADHD and HRT medication as being in short supply. Obviously, that is an incredible frustration when you are at the interface with patients. Do you agree that it would be helpful within the Department to reconstitute the medicine supply team in order to address the issue of medicine shortages? Can I ask both of you that question?
Deborah Evans: I can pick up on the supply theme. We, too, have the same frustrations. I cannot imagine, if you are doing 300, 400 or 500 items a day, how much work and frustration there must be for the pharmacists and their teams, trying to get stock and to interface with the patients. They are at the frontline dealing with patients. I have it on a much smaller scale, but it takes a disproportionate amount of my time to address it.
There are some potential solutions, but we need to understand that, if something is out of stock, it is out of stock. It is not that somebody is sitting with five packs on their shelf. The stock has been exhausted. People have already done their traipsing around. We are repeatedly getting people in for ADHD medicine. I am in the fortunate position as a prescriber prescribing HRT that if something is not available I can prescribe an alternative, but otherwise it requires a lot of liaison with GP practices.
Of course, the whole thing spirals down. Here is a resource, a sector, which is on its knees in terms of capacity. Then you throw in the supply chain, which requires another two, three or four hours a day to deal with. That is activity that that team cannot be doing if they are to deliver all the other things that we want them to deliver, so it becomes a perfect storm of issues. Yes, absolutely, the supply chain is an issue wherever you are, but the bottom line is that if it is out of stock at the wholesaler, and has been out of stock for some time, there won’t be any stock anywhere to be able to have a technical solution and to be able to find it. Therefore, how do we communicate with patients? How do we get upstream with GPs so that there is an intervention at the prescribing level before it comes down to the dispensing, and the issue is addressed?
Q79 Rachael Maskell: Finally, William, do you think the solution should be found in the Department rather than in pharmacies, with regards to the supply chain? Should there be a more consistent approach around that?
William Pett: To be honest, that is an issue that falls outside my area of expertise, and indeed the work of Healthwatch England. All we can say is that at the moment shortages are affecting patients across the country, causing real issues. Where that solution is found is a decision for Government, but at the moment something must be done.
Q80 James Morris: Mr Pett, I want to come back to your second C—culture. We talk quite a bit about the resistance of patients to access pharmacy services for various reasons. Do you think there are other resistances of which we need to be aware?
William Pett: Sorry, can you repeat the question, please?
Q81 James Morris: Your category of culture speaks to resistance and reasons why people will not access pharmacy services. What sorts of other issues are in there beyond the ones that we have already talked about?
William Pett: It will take time. We cannot expect patients to suddenly change their behaviour and instantly be aware that pharmacists offer these new services, and indeed have the confidence that pharmacists will be able to deliver as good a job as their GP. There is a time element. There is only so much you can expedite in changing public behaviour.
We have done some research, not only on the Pharmacy First conditions but where patients might want pharmacy to go in future in longer-term expansion of services. We found that over half of the public said that they would feel very comfortable going to their pharmacist in future for a wider selection of vaccinations—for example, HPV and shingles. Those vaccinations could be delivered in pharmacy, and the public would be very happy to go to pharmacies for that. Equally, with dermatology services and treatment for things like eczema, acne and psoriasis management, there is generally high support among the public for expansion into those areas. Less so about menopause advice. We asked about that and there was quite low likelihood of the public going to the pharmacy for that; similarly, for management of long-term conditions.
We need to give the public assurance, certainly on the menopause advice point. Again, this comes down to the issue of sensitivity and people feeling more comfortable going to their GP when there is a degree of sensitivity around the condition. At the moment, patients are not confident that they will have privacy.
Q82 James Morris: Do you think they are justified not to have that confidence, in the sense that it is an emerging area and pharmacies are being asked to do different things and there is lots of change? Do you think they are justified in not feeling confident?
William Pett: Yes, they are justified. Partly why they are justified is that patients know themselves how overworked pharmacists are. They will be experiencing it themselves on a week-by-week basis. We have also had some local Healthwatch doing investigations into what the private consultation rooms in pharmacies actually look like. When there is investigation into that, many pharmacists offer not much more than a curtain when giving advice.
Q83 James Morris: The reason I ask is that I wondered whether in your culture thing there is resistance within the profession itself to change and to be able to take on some of these services, reflecting changing patient needs. Do you think there is some resistance to change within the profession itself in pharmacy?
William Pett: Possibly.
James Morris: I will ask Deborah.
William Pett: Again, that is not our area of expertise, but we would not be surprised if that was the case given the pressures that they are under just delivering existing core services, let alone Pharmacy First. That may be something that—
Q84 James Morris: Deborah, you are an innovator. You have gone out there and started a business. Do you think there is resistance to change within the pharmacy profession. Are they paying lip service to the idea that we need Pharmacy First but, actually, “It’s all a bit difficult and wouldn’t it be better if we just stayed the way we are?”
Deborah Evans: It is like anything; you are going to have the rule of thirds. You are going to have people who are really engaged and want to push things forward. You are going to have those who will go with the main core, perhaps after a while. Then you will have those who are more resistant to change.
I worked with the Government about 10 years ago to implement and lead the Healthy Living pharmacy programme, which is around getting pharmacy much more engaged in a proactive role in prevention—public health. I am pleased to say that it is now part of the essential services in the contractual framework. As part of that process, yes, we met resistance. It is about purpose. That is why I mentioned earlier that there should be an element of change management underpinning the shift. Most people working on the coalface are not contractors. They do not have a financial interest in that business. What they are interested in is delivering the best care they can for patients, whatever that looks like. At the moment, 99% of their time will be occupied in clearing scripts and dealing with supply issues. Unfortunately, there is very limited capacity to do the things that they might have a desire to do.
Q85 James Morris: Thinking about the workforce for pharmacy, in order to be able to meet the emerging landscape for the different services, do we need to think about a different workforce mix in pharmacy to be able to deliver the change that is required?
Deborah Evans: Certainly, and there are some moves already in place to make that happen—for example, increasing the number of prescribing pharmacists and giving more autonomy, responsibilities and accountability to other members of the pharmacy team, such as pharmacy technicians, who are also registered practitioners.
Coming back to your point, Paulette, the profession is regulated by the General Pharmaceutical Council. We have GPhC in the room today. I think it is important to recognise that there are other ways of delivering the service, but you have to have the headspace in any business model—whatever that business model is, whether you are working for a corporate or an independent—to be able to think about how you can find efficiencies to try to make the bulk of the work as easy, straightforward and safe as you possibly can. At the same time you need to release capacity and have the competence and capability to be able to deliver the sorts of things that we are talking about and need to deliver for the future within primary care.
Q86 James Morris: Do you have any thoughts on the workforce challenge, Mr Pett?
William Pett: May I come in on the pharmacy technician point?
James Morris: Yes.
William Pett: Broadly, it is very understandable why some of the workforce challenges could be alleviated by expansion of what pharmacy technicians could offer. From a patient perspective, our sense from our research is that patients would welcome the increased use of pharmacy technicians, but only on the basis that they feel informed and aware of the difference between a pharmacy technician and a pharmacist. We would be concerned about patients seeing a pharmacy technician thinking that they are seeing a pharmacist. Our evidence shows that, when patients are taken through who they are seeing and what the role is of that professional, there is generally a good experience of care. The point around patient education and awareness is really important.
Q87 Paul Blomfield: There is one issue I would like to pick up on, which William talked about at the outset, but I don’t think we explored it. It is about pricing. You gave an example of somebody who preferred to feed their kids rather than treat their reflux. Reflux is an awful condition. That says a lot about where we are as a society at the moment.
Specifically, from the work that you have done, how far do you think that the current model of prescription charging and exemptions is fit for purpose? I say that partly as somebody who has been getting free prescriptions now for five years. I am embarrassed because I know I can afford to pay, and I can see that other people cannot. I accept the principle of universalism. I understand the simplicity of it and a contributory system, but I wonder if the resources could be directed more intelligently to support the people most in need.
William Pett: In answer to your question, absolutely. When you look at the exemption categories at the moment, there is a certain degree of inherent unfairness in them. Certain groups of patients are excluded from charges. For example, those with diabetes are excluded from charges, but if you have asthma you are not exempt. Similarly, cancer patients are exempt, but if you are somebody who has had a life-saving operation and you are then reliant on immunosuppressants, you are not exempt.
We think there is some reason to revisit the exemption categories. Our fundamental point comes down to the fact that there are some mechanisms to help alleviate costs for patients that, at the moment, are not being used. It is baffling to us, for example, that prescription pre-payment certificates offer some support to patients, but there is such low public awareness of them. That should be changed so that patients know how they can be supported.
Q88 Paul Blomfield: Why is that? The pharmacy would be the point for raising awareness. Aren’t pharmacists trying to promote that?
William Pett: We do not have evidence on that. I imagine that it varies, but I think national action is needed to ensure that it is not just pharmacies that are raising awareness of those schemes.
Q89 Paul Blomfield: I take that point. I am just thinking that where people actually pick up on information relevant to them is at the point where it resonates. Should pharmacies be the place where that is done as part of a national initiative?
William Pett: Yes, absolutely, but at the moment more needs to be done to make sure that patients on low incomes can afford prescriptions. At the moment our data shows that a good proportion of patients avoid going to the pharmacy. We know that that is storing up problems further down the line for the rest of the health and care system. The Government need to get a grip on this, not least from a prevention perspective.
Q90 Paul Blomfield: Deborah, do you want to come in?
Deborah Evans: Prior to setting up the business, I worked in an NHS pharmacy locally for 10 years. We promoted the pre-payment certificates, but if you are in the situation where you have to choose to pay for food at the local supermarket, paying a lump sum up front is out of reach. I have no idea what it is now, but it is significant whether you do the three-month, the four-month or the 12-month one. That is an investment up front. Maybe there is something about looking at the structure of that, by paying monthly or having some sort of saving related to it.
At the end of the day, community pharmacy is not paid to take this tax for the Government. It is a prescription tax. There would have to be something in it for the pharmacy to do it. I know that sounds unpalatable, but the bottom line is that there are so many things that community pharmacies are doing free of charge. The extensive delivery service to housebound patients, of which my late mother was a recipient, is not funded in any way at all unless the pharmacy chooses to charge the patient. We have to acknowledge and recognise that. These are private contractors, just as GPs are. It is important to pay appropriately if the Government want a service to be delivered.
Paul Blomfield: Thank you.
Q91 Chair: Earlier on, you were talking about your ability as an independent prescriber to look at alternatives. I know we will talk about this in the next panel, but I was wondering whether you think there is a lack of strategy for the use of independent prescribers across the wider community pharmacy sector.
Deborah Evans: Yes, I do. We must really think this through and make sure that we are using independent pharmacies. A lot of my colleagues are becoming qualified as independent prescribers, and then there is no commissioned service within the NHS for them to deliver. We are using patient group directions as part of Pharmacy First. What is the motivation for pharmacies to invest their own time in that development?
Of course, fast forward 10 years and we will have all the young ’uns coming out of university qualified as prescribers, but we have a transition period and we need to make sure that we have thought that through. For me, I am using my independent prescribing privately. I am sure that is what my colleagues will do in community pharmacy. It is a far more profitable service for them as well to deliver a private service. There was Paulette’s example of the travel vaccination services that she was a recipient of. Increasingly, my colleagues, in order to have sustainable businesses, have to look at private services. What is then the consequence for the NHS service alongside that?
Chair: I praise the use of the term “young ’uns”, which I don’t think we hear enough of these days. I know that you are referring to people like me and my colleagues—
Mrs Hamilton: The one-and-a-half-year-olds.
Chair: Yes. Excellent. Thank you very much for an excellent first session. We will take a break for five minutes max while we change the panels. Thank you so much, William Pett from Healthwatch and Deborah Evans from Remedi Health in Winchester for giving evidence.
Witnesses: Mark Koziol, Duncan Rudkin and Nicola Stockmann.
Q92 Chair: Welcome to the second panel in our second public evidence session of our inquiry into pharmacy, both community and hospital. We are now looking at the workforce. We are going to talk about all the issues around what a pharmacist or pharmacy technician of the future might look like, the challenges that that brings to the sector and the opportunities that it brings to the sector.
Before us, we have Mark Koziol, chairman of the Pharmacy Defence Association. It is nice to see you. We have Duncan Rudkin, chief executive of the General Pharmaceutical Council, which was referred to in the last session. Your fame goes before you. We have Nicola Stockmann, who is vice president of the Association of Pharmacy Technicians. Thank you so much for coming in. We are probably going to run this for about 45 or 50 minutes, certainly no more than the hour. I am going to start with you, Duncan.
One of the live things at the moment, when we talk about the pharmacy workforce of the future, is that there is obviously a lot of debate around pharmacy technicians and how they sit alongside pharmacists. As you heard, we were talking a bit about independent pharmacy prescribers being able to deal with medicine shortages, which is one of the biggest challenges facing the industry at the moment. What is the biggest issue facing the pharmacy workforce at the moment?
Duncan Rudkin: It might strike some of my colleagues as odd if I start with wellbeing. We have not mentioned that so far this morning. From where we sit, we are very aware of issues affecting the wellbeing of the profession and we are very mindful of the fact that that then has a patient safety implication.
Obviously, as a regulator our primary focus is on the safety of the public and the safety and wellbeing of patients, but we see that as inextricably bound up with the wellbeing of the profession. We know that in many ways members of the profession are having an exceptionally difficult time at the moment. I would want that to be high on the agenda. I am sure we will come back to it.
Secondly, and more obviously from a regulatory point of view, is everything to do with the skill, competence and capability of both pharmacists and pharmacy technicians and, I would say, the wider pharmacy team, including members of the team who are not registered. For us, as the regulator, it is ensuring that the people we regulate in every sense have the skills, competence and confidence that they need now and in the future. That is a key, strategic objective for us. There is a lot of work going on around that.
There is a really important set of issues that are, to quite an extent, legal but also regulatory and professional, around skill mix, by which I mean making sure that all of the elements are in place to enable all members of a team to maximise their contribution to care, so that pharmacists are doing what only pharmacists can do and pharmacy technicians are able to optimise their contribution. Other members of the team can do the same. Some of that is about confidence and competence. Some of it is also about making sure that the legal and regulatory framework enables all of that. I will leave it there with those three main headings.
Q93 Chair: As you are the regulator, I will ask you this. The NHS long-term workforce plan says that education and training places for pharmacy need to grow by between 31% and 55% by 2032-33 to meet the demand for pharmacy services. It also talks about expanding training places for pharmacists by nearly 50% by 2031-32. In your opinion, is that plan deliverable?
Duncan Rudkin: That is obviously a very ambitious set of objectives. We have in mind a shorter time horizon around the deadline of 2026, when all newly registered pharmacists will be annotated as prescribers at the beginning of their registration. Currently of course, as you know, becoming a prescriber is an additional qualification, effectively an annotation.
We brought together a group of all the key actors who are looking to try to effect that 2026 change. We know that a key issue, a key concern and a key risk in that change, which our colleagues are concerned about and are continually working on, is around making sure that there are adequate placements, with the right clinical exposure and, very importantly, an adequate supply now and in the pipeline of existing prescribers who will be able to support the training of prescribing pharmacists.
We know that there are challenges now, which we and others are working on, around getting to the 2026 change. Looking beyond that, there are obviously a number of different elements to the objective you outlined, Chair, including making sure that there is an adequate supply of MPharm places for training pharmacists and making sure that there are adequate numbers, quality and breadth of training placements, and the trainers to support those trainees in future.
Q94 Chair: Help me to understand this. William Pett from Healthwatch was saying that the community pharmacy sector has had a brutal haircut, and there are smaller numbers than ever. Yet we are talking about growing the workforce by up to 55% to meet demand for pharmacy services. My simple brain says that there is going to be a gap between the numbers that we are talking about bringing in, if that is delivered, and the places where they might deliver those services, or am I missing something?
Duncan Rudkin: We have to look at the numbers of pharmacists as well as the numbers of pharmacies. The numbers of pharmacies have gone down in the last few years and we have seen an increase in the number of pharmacists on the register. There is a debate raging, one might say, about whether the system as a whole has the right numbers of different types of workers in the right places, but we have not touched so much on hospitals. There are obviously a significant number of training places in hospitals which would be part of the overall training capacity.
Q95 Chair: Let’s do that then. It is a perfect bridge to Nicola. Obviously, you have a role at Hampshire Hospitals. It is becoming Hampshire day. Hampshire Hospitals trust partly covers my constituency, with the Mid Hampshire trust. What do you think about the long-term plan ambition and its deliverability with respect to hospital pharmacy?
Nicola Stockmann: That is a really interesting point. Thank you for that. I would like to caveat it by saying that I am here in my capacity as APTUK vice president, but you are absolutely right that I have a day job at Hampshire Hospitals.
Q96 Chair: For those watching, could you say what the acronym you just gave means?
Nicola Stockmann: The Association of Pharmacy Technicians UK and Hampshire Hospitals Foundation Trust. In the workforce plan, we have a pledge to grow pharmacy technicians. There are not as many numbers on that as there are for pharmacists. It is about having the right people in the right place with the right skills for the patients who need them. From a hospital point of view, there are more pharmacists per place than there are in a pharmacy in the community. Their knowledge and skills are far more utilised. There are not many of them and they are looking to deliver more. There are more wards and more patients coming in.
It is tough in pharmacy at the moment. To make sure that we have the right people in the right place, we need to look at the skillsets of everybody—pharmacists and pharmacy technicians—so that the model we have is fit for the future. In hospital and community, that applies across the board. Pharmacy is a very valued service, but there are never enough of us.
Chair: I am not going to go to everybody on this because other colleagues want to put questions to Mark. I am going to go to Paul Blomfield first. Paul, you can pick up the threads.
Q97 Paul Blomfield: Let me take that cue and put a question to Mark. Duncan focused on the issue of wellbeing in the profession. We have had some pretty damning evidence on the pressures on pharmacists. Certainly, when I have talked to community pharmacists in my patch, they are committed people who are struggling. How would you describe morale in the workforce?
Mark Koziol: First of all, thank you very much for allowing this Committee to hear the voice of the workforce. It is not something that happens very often. Pharmacists tend not to get too much of a voice in this situation.
We represent employee and locum pharmacists. We are a defence association. We help them when things go wrong, so we understand an awful lot about the causes of issues. Much of what I am going to say to you is fuelled by morale at this moment in time. We don’t have any owners in our organisation, just employees.
What happened with the funding cuts, which had nothing to do with our members, ended up with massive staffing cuts. It was the only mechanism that the employers had available to them to try to make ends meet. We have seen huge cuts right across the sector in community pharmacy. I am talking particularly about England, all parts of England: 20% is the cut in the number of pharmacy technicians who are available in community pharmacy reductions now in England, compared to what it was just five years ago. We have cuts in all of the other grades of staff. Meanwhile, the volumes have gone up and up.
It means that the pharmacists, who are all healthcare professionals who want to help patients—the only thing they want to do is to make patients better—are forced into a situation where they cannot follow all the protocols as they should. They have to start making decisions as to how to make ends meet and how to deliver services for patients in a deteriorating environment. That is not an ideal condition in which to practise for six months or a year, let alone for three years and five years. That is what has been happening and it has had a huge effect.
On business behaviours, in community pharmacy in England there are some very large multiple operators. They are owned, many of them, by large corporate businesses who want to buy and sell those businesses. While they are buying and selling those businesses, they have to do things like cut holiday entitlement and pension arrangements. There are non-pharmacist area managers giving people commercial targets as opposed to clinical arrangements around patients. Those arguments cause all sorts of problems.
You then have the problems around the shortages of medicines. Members of the public, quite understandably, are coming in and the only people they can vent their fury on are the pharmacists and the pharmacy staff they are facing. In secondary care or even in GP practice, it is often the receptionist or people at the front of the hospital who get that. In the community pharmacy, they get it as people walk in off the street.
On top of that, there was the covid crisis. As you know, community pharmacy was the only place that was accessible and open to members of the public, with all of the incumbent problems, frustrations and grief that that brought. You end up with community pharmacists facing lots of violence and abuse.
We give £1 of every single one of our membership fees to Pharmacist Support, which is a charity that looks after pharmacists who are on the edge of mental health issues, wellbeing issues and concerns around that. They have been at record-breaking levels these last few years. Morale currently in community pharmacy and the staffing shortages that continue to be in position have massively affected the morale of the community pharmacist workforce.
Q98 Paul Blomfield: That is a depressing start for our discussion. You paint a multifaceted problem. As a Committee, we are looking to make recommendations to Government. Where would your recommendations be in seeking to begin to address those issues? What are the priorities?
Mark Koziol: There are lots of exciting developments on the horizon. As has already been mentioned, the independent prescribing qualification is a major one. The answer to your question does not just apply to pharmacy. It applies to the whole of healthcare, but particularly primary care. Why don’t we start working smart and not just working hard?
We have a situation today where about 7% of hospital beds are filled by patients who have been harmed by adverse drug reactions, and 20% of over-65s are admitted to hospital because of the effect of adverse drug reactions. Medicines are the second largest item in the NHS budget, yet what care and attention has been paid to medicines specifically? Pharmacists are the healthcare professionals who are trained in medicines, so I think the answer to your question is to get pharmacists to be pharmacists in the healthcare system. Get them to focus on medicines issues. That will be to the benefit of the public and the NHS. A large proportion of people are trying to contact their GP every day and they cannot get through. They have already been diagnosed by the doctor, so now it is a question of getting their maintenance doses of whatever it is, cardiovascular or diabetes. Those medicine management issues could be taken care of by pharmacists. The patients need not go back to the GP surgery and that will have the inherent effect of reducing the queues that the GP practices are facing.
We would say that the exciting possibility for independent prescribing is to enable patients to get a medicines champion. The pharmacies should be the patients’ medicines champion. As Deborah pointed out in the earlier presentation, it takes about half an hour to do a really detailed assessment and to get patients to build up trust in pharmacists and see them as an agent for beneficial change. That is all about more than one pharmacist in a pharmacy. There is no question about that. The existing workforce infrastructure is so fragile that you could not add any more services on top of it. It is already at breaking point. You need to start moving the community pharmacy so that it becomes more of a clinical operation, with more than one pharmacist working there and at least more than the complement of pharmacy technicians that we have at the moment, which is one per two pharmacies.
Q99 Paul Blomfield: You make a really striking point. It is a substantial culture change. Do you think that the pharmacy sector is comprehensively and consistently ready for that across the country?
Mark Koziol: It depends on what you call the pharmacy sector. Are you talking about the owners and the employers, particularly the large corporates, or are you talking about the actual workforce? I can talk for the workforce. They want to care for patients. They want to use the skills that they have been taught at university to the best effect. When we do focus groups with our members in the surveys, one of the biggest frustrations of the young ’uns, the phrase that was used earlier, is, “This practice doesn’t resemble what I was taught. Why aren’t I using my skills, particularly in the community pharmacy setting?”
The workforce are ready for that, subject to us being able to alleviate some of the crazy staffing shortage situations. If we could create a safe environment where they could spend enough time with patients, they would embrace that clinical role. Your question about whether the business operators are ready for that kind of change is another question altogether.
Q100 Paul Blomfield: I am sure that we will come back to those issues. Nicola, what is morale like for pharmacy technicians?
Nicola Stockmann: It is very much the same. Pharmacy technicians, because it is an apprenticeship route, as soon as they are training, are in the workplace. They are in the environment that we are describing. They are under a lot of pressure. From day one, that is their learning environment. In the same way, post their university experience, that is the learning environment of pharmacists in their training year. It is tough. I think we need to support each other in the pharmacy professions to make sure that we are investing in the future workforce, as well as retaining the ones who are there.
When the workforce plan talks about training and retaining, and what that looks like in the future, actually training and retaining are linked. Those who are retained in that environment are the ones who are teaching, overseeing and supporting those who are starting on their career. Those early years are really important.
You are completely right. They are at the frontline. There are frustrations from medicine shortages. People are potentially frightened. We heard in the earlier session about someone who really needed something checked out. Patients come to the pharmacy because they need reassurance. They need support from pharmacy professionals who are trained to deal with it. Basically, what I am saying is that we need them for the future. If we do not get the early years right, we are going to see retention drop off. I cannot stress enough how important those early years are. Training and retaining are so inextricably linked that morale is tied to the environment in which they operate. That is reflective of the answers you have heard from everyone.
Q101 Paul Blomfield: Thank you very much. I am sure we will come back to some of those issues. Duncan, you are itching to come in, but I want to ask you something specific, and this is an opportunity to make another point. In your submission, you talked about prejudice, discrimination and racism as a problem. How widespread is that? Can you elaborate on it and what needs to be done?
Duncan Rudkin: We have had lots of really interesting and important discussions with a range of different colleagues from different parts of pharmacy over the last year or so, particularly around this topic. As a result, we are raising the profile of the issue in our own work, and thereby also hoping to encourage others to do the same and to be part of the wider conversation.
First, we obviously have some important statutory obligations. More fundamentally, it is for reasons of humanity and doing the right thing. There is also a really important link with capacity, capability and confidence. We have heard upsetting and distressing examples and stories from colleagues in pharmacy in different settings, whose confidence and ability to optimise their contribution to patient care has been dented by their experience of, for example, racism in the workplace. It is important that that is tackled for all sorts of reasons. There is a link with patient care. That is clearly, and rightly, a high-profile issue. The chief pharmaceutical officer for England leads the Inclusive Pharmacy Practice board, which is also helping to raise the profile of the issue and to challenge all of us to do more and do better to tackle discrimination, racism, bullying and harassment in the pharmacy workplace. It can be so corrosive in all of those different ways.
I want to add briefly to what Mark said in answer to your question about morale. We heard some of this as well in what Mark said later on. In the various engagement events we have held in the last year or so with pharmacy team members, in listening events, as well as in all the informal conversations we have had in a range of different settings, there are all of the things that have been described. There is also a considerable degree of enthusiasm and excitement for change. I do not myself see resistance to that as a key issue in the profession, but there is a realistic and quite proper concern by pharmacy professionals about these questions. Are we going to be able to maximise what we can do? Are we going to be able to take advantage of the opportunities, which we want to do? That is what I am hearing. For example, because we spend so much time dealing with shortages, we have all the pressures that you have been describing. I believe the will is there, but there is a proper set of questions being asked of all the various authorities involved: “You all need to make sure that we are enabled and supported to do this, but we really want to.”
Q102 James Morris: Mr Rudkin, obviously there is a huge amount of change happening in the sector—new demands, and so on. Do you think that changes what you need to do as a regulator?
Duncan Rudkin: Yes. It certainly changes what we do and how we need to go about it. We have been looking at that ourselves in our own organisation, at our own competence and capability and what kind of skills we need to have within the regulator. It is not so long ago that we were dealing with concerns and complaints that would pretty much all be about dispensing errors, supply issues and so on. We are understandably seeing a growing case load around clinical issues, which has encouraged us, effectively, to build a new team.
Q103 James Morris: When you say clinical issues, do you mean malpractice that then gets escalated to you?
Duncan Rudkin: I mean, for example, issues around prescribing judgments. It is that kind of thing, which would not have been in our case load previously. In response to that, and looking to the future, we have been looking at a different kind of workforce within the GPhC. We have always had inspectors who were mainly pharmacists, but with some pharmacy technicians. A growing proportion of those have been recruited specifically as clinically focused inspectors. Many of them are currently prescribers themselves and are still actively prescribing. We are building our capacity and capability to understand the issues. We have recently hired a senior pharmacist as our first chief pharmacist in the regulator, to strengthen our ability to engage with the profession across a range of issues.
Q104 James Morris: Nicola, the pharmacy technician role is relatively new. I wondered how you felt it was working in terms of fitting into the pharmacy environment.
Nicola Stockmann: Thank you; that is a great question. You are absolutely right that the profession has been regulated since 2011, so compared to pharmacists, yes, we are fairly new. We definitely have a place there and we have supported capacity in the pharmacy teams. We have a home within the pharmacy, but what we are seeing is that we could do more. The potential, following the initial education and training from 2017 that is now embedded in pharmacy technician training, means that we come out as accuracy and checking pharmacy technicians. We can check prescriptions for accuracy before they go out to the patients.
We can do more. We are talking about capacity. We can see that there is potential for our profession. Regarding the consultations, one is out now around supervision and one has just closed around patient group directions. There is a place for pharmacy technicians in that. We have the skills, knowledge and behaviours to be able to support that. We are putting patients first. We are held to the same professional standards as pharmacists by our regulator. We are well placed to support the capacity, and the potential is only greater.
Q105 James Morris: Do you think the public understand what a pharmacy technician is?
Nicola Stockmann: Probably not enough. The reason I say that is that even in the first session, for example, it took a while for pharmacy technician as a profession to come into the discussion. There is definitely some work we need to do around that on positive reinforcement from other professions. In the same way that confidence in pharmacist independent prescribers needs to be reinforced by other professions, it is the same within the pharmacy profession for us. Pharmacists need to reinforce confidence in pharmacy technicians. We need to do it ourselves, but it is about looking at the patient journey and how we all link in for the patient, and breaking down some of the more traditional barriers. We all need to support each other in that, and it goes wider than pharmacy.
Q106 James Morris: Mark, you painted a picture of a profession where morale was pretty rock bottom or pretty low. What needs to happen in order to raise morale? What recommendation would you make to us?
Mark Koziol: The big question that came up in your last session in November and this morning is the whole thing about sourcing and purchasing medicines, which I know Committee members are interested in.
When I first qualified as a pharmacist, I spent a lot of time mixing creams and ointments. That has all been taken away. It is all done in factories. Some of our members now spend four and a half hours a day trying to find one medicine, so they are not facing patients in a clinical situation. If we could move away from the pharmacist being involved in the purchasing, the sourcing and the buying, and all of the prescriptions were generated electronically so that when the pharmacist arrives in the morning those medicines are already pre-bagged and pre-checked in the pharmacy—there is technology that can enable that to happen—pharmacists will spend all of their time on clinical issues as opposed to assembly and preparation. During the supervision sector group report that convened over the last six months, that was one of our recommendations to the Department of Health. Change the legislation to allow assembly in some other way, so that when the pharmacist arrives in the morning their role is the clinical check. That is where the value is.
That would take a huge amount of unnecessary workload away from the pharmacist. Then it is a question of dealing with the clinical issues for patients. There are two elements to that. There is the appointment-led caseload work, where we take pre-diagnosed patients from doctors and help them maintain their diabetes medicines and asthma preparations. The second one is the population health model: our pharmacist is standing there, patient facing and in comes a patient who wants to buy an anti-diarrhoea preparation, but the pharmacist knows that that patient is taking an ACE inhibitor and immediately has to advise the patient to stop taking the ACE inhibitor for the next two days, otherwise they are going to end up with acute kidney injury. In the UK, 150,000 people a year die of acute kidney injury. That is the kind of clinical application in a population health model that community pharmacists could do.
Q107 James Morris: That is a fundamental shift in the kind of business model of the pharmacy.
Mark Koziol: Absolutely.
Q108 James Morris: Would you agree with that as the future direction, Mr Rudkin?
Duncan Rudkin: In as much as it is about maximising the contribution that each member of the team can deliver and using technology in the right way. Absolutely.
Q109 James Morris: Nicola, do you think technology has the potential to achieve the transformation that we have been talking about?
Nicola Stockmann: Absolutely. If there are certain elements of the pharmacy service that can be automated safely, that frees the pharmacy professionals to best utilise their skills in patient facing, which would then reassure the patients in confidence in pharmacy, which can only be a good thing.
Q110 Chair: On the medicine shortages, Duncan, you said in your written evidence to us that there was “unprofessional behaviour associated with medicines shortages”. What did you mean by that?
Duncan Rudkin: A few months ago, leading a discussion with the other professional regulators, we issued a joint statement to all of the registered healthcare professionals in the country, reminding them of, for example, a national patient safety alert in relation to GLP-1 agonists. I am not a pharmacist, so forgive me if I do not get the exact detail right. This is where medicines that are in serious shortage and needed for use by diabetic patients may be in some cases being prescribed off-label for other purposes, including particularly weight loss. There is something around making sure that prescribing judgments are mindful of shortage issues.
If I may, Chair, while on shortages there are a couple of other things I want to mention. One is that some years ago there were introduced things called serious shortage protocols. I do not know if you have looked at those, but I am sure you are aware of them. It may be time to look at whether there is more that can be done with those. The other thing picks up on something that Deborah talked about earlier, which was her ability as a prescriber to prescribe an alternative in the case of a shortage medicine.
There is a lot of focus on prescribers. There are 40,000-odd pharmacists on the register who are not yet prescribers but have a lot of core underlying skills and competence based on, in many cases, years of over-the-counter prescribing. Is there more we can do with them in looking at the legal framework around when a pharmacist is able to vary what they supply against a prescription, in order to make the most of their knowledge and skill? That is perhaps just an example of a wider issue about the non-prescribers. It is important that we do not miss out on that large number, and focus all of our energy on the new ones.
Q111 Rachael Maskell: Thank you; this is a fascinating discussion. Duncan, I would like to start with you. I want to ask about regulation. We are seeing a greater skill mix now being introduced into the NHS. We have talked about Pharmacy First and the expanded role there. There is also the importance of having independent prescribing. We are seeing skills move not just within the traditional silos of the profession but stretching more broadly into areas that other professions would have covered previously.
Is the new legislation around regulation fit for purpose? Are there other changes that we need to see to the regulatory framework in order to ensure that there is not only clarity of role but that patients understand that clarity of role? How can that be improved?
Duncan Rudkin: I am trying to think where to start because there is a lot in there. On clarity of roles to begin with, one of the messages that we have had from our discussions with patient groups in different ways, and a panel that we run, is a recurring theme around a real willingness and openness to being cared for by pharmacists and pharmacy technicians perhaps in ways that people have not been used to. As one patient said to me very clearly, “I don’t care who they are, as long as they know what they’re doing.” From a professional point of view, we often spend a lot of time worrying about labels and titles, so that was a different point of view on that.
In terms of regulation more widely, there are a couple of things to say. One is around professional regulation generally. For many years it has been the subject of discussion on reform. As you know, there is an order going forward to begin the reform of GMC procedures. It is really important that I take this opportunity to commend to the Committee the agenda around reforming professional regulation to streamline processes, to make sure that the regulators have and can use the tools that we all need.
Q112 Rachael Maskell: What do you mean by that?
Duncan Rudkin: For example, making decisions about fitness to practise in a more agile and rapid way. Those issues cut across all the health profession regulators, but there are some specific issues relating to pharmacy that are worth picking out.
The way in which the pharmacy regulatory regime was set up in 2010, when the GPhC was created, involved, as you know, the regulation of individual pharmacy professionals—pharmacists and pharmacy technicians—through the GPhC very much along the lines of the GMC, GDC and NMC professional regulation paradigm. We have an unusual, if not unique, arrangement whereby community pharmacy premises—legally defined as retail—are registered, regulated and inspected by us. They do not come within the remit of the Care Quality Commission, for example, in that respect. Our regulatory jurisdiction is based on a building, the premises, being registered. That made sense perhaps when it was originally designed. I think it is something that needs to be looked at. Of course, services are now operating in a way that is not necessarily tied to a particular building, as we have seen with some of the online issues.
There is an entirely sensible discussion to be had around the question of whether other models of regulation might be more appropriate or relevant going forward in pharmacy, such as whether the business entities themselves should be regulated. They are not currently, strictly speaking, which is a contrast for example with the General Optical Council.
Additionally, it is incumbent on us, working with other regulators, including in England particularly the CQC and MHRA, to make sure that between us we do not allow anything to fall between the cracks. There is a regulatory gap which I take the opportunity to draw to your attention. It is linked with the business about pharmacy premises being regulated by us. Where a business sets up a service using pharmacists to provide clinical care, but not through a pharmacy, it is not liable to be regulated by us because there is not a pharmacy if there isn’t any supply going on. Equally, it falls outside the Care Quality Commission jurisdiction because it is a pharmacist service. I can write to you if it is helpful to give you a bit more background. That gap has been something that we and the CQC have agreed ourselves that we want to see closed. We have asked Government to look at that.
It is important. I mention it as an example of needing to look perhaps creatively at the regulatory furniture to make sure that it is right for the future and not an old model that is not serviceable. We have a piece of work planned for this year to look at that from our point of view. It is possible that, as a result of that, we ourselves might suggest legislative change around some of those issues.
Q113 Rachael Maskell: Very quickly, on the issue of businesses and buildings, are you suggesting that that should transfer to the CQC?
Duncan Rudkin: No, I am not necessarily suggesting a solution. At this stage I am just flagging that there is an entirely sensible debate to be had about it. The further away service design gets from being tied in a neat way to a particular building, the more strain it puts on a regulatory model that was designed in a different era.
Q114 Rachael Maskell: Mark, I saw you nodding. Do you want to respond to that? Then I have a further question for you.
Mark Koziol: It won’t surprise Duncan to hear, because we have maintained this position for years, that we believe community pharmacy premises should be looked after by the CQC. There is no question about that whatsoever. Not only that, the business owners need to be regulated. In community pharmacy there is a unique situation where we have non-pharmacist area managers. These are people in a very substantial position of influence in healthcare.
In other sectors—finance, for example—people in positions of influence are regulated by the regulator. Why does that not happen in community pharmacy? A classic case in point is where a pharmacist might decide not to sell a particular item to a patient because it is not safe. We have had situations where area managers have got involved, taken the thing off the shelf, sold it to the patient and said to the pharmacist, “If you ever do that again, you’re in trouble.”
We have to involve the regulation of people who operate the businesses and non-pharmacists in the healthcare space. We believe the right place is the CQC. We believe that the GPhC should concentrate on the people regulation. As Duncan says, community pharmacy is now much more integrated with the wider healthcare patch and the delivery of the services, so that kind of regulation would not just give patients more confidence, it would give the workforce more confidence that, if they have issues with their workplace and their environment, there is a regulator that has a good track record of dealing with those situations elsewhere. We have often said to the GPhC that the position is quite overwhelming for the GPhC, given the amount of stuff that goes on in community pharmacy. That is something that we would certainly back 100%.
Q115 Rachael Maskell: Again being really quick because of the time, there is the issue of commissioning. We have a new structure within the NHS with ICBs. What role should pharmacists have in the structure of commissioning at that level?
Mark Koziol: It is like a football team. That was an analogy that was used in the November session. If we are not careful, we are going to have all the focus on the strikers, but we need the defenders and wingers in there. Most importantly, we need a manager. The ICB should be the manager of what goes on in that healthcare patch. It should deploy the resources, marshal the forces and make sure that we do not have silos going on. For that to happen there needs to be a multidisciplinary team in the ICB. There needs to be a chief pharmacist at ICB level. That is really quite important.
Beyond that, for example, there was ARI funding given to have a whole army of PCN-funded pharmacists. If there was an army of healthcare professionals that could be deployed in any of the healthcare settings—in a doctor’s practice, in a care home, in a community pharmacy—it would enable the primary care organisation to deploy their forces far more effectively than is currently the case. On the big argument about all these pharmacies being taken out of community pharmacy to go and work in GP practices, we have no problem with pharmacists being employed by a PCO but let’s deploy them where they are needed and not just send them into one particular corner. It just continues to support a broken system.
Q116 Rachael Maskell: My final question is to both Mark and Nicola on the issue of training. The Government have put forward a high ambition for increasing the size of the workforce. Without having experienced clinicians providing the training, clearly that will not stand up. Moving forward, do they have the right balance?
Mark Koziol: We saw a huge increase in the number of schools of pharmacy about 10 years ago. When I was a pharmacist there were only 18 schools. Now there is nearly double that number. There have been problems at the university schools. In the same way as the community pharmacy workforce are stretched, the academic workforce are stretched. Where do you get the experience to suddenly double? There is talk of another half a dozen schools opening. That is going to give somebody—I suspect the regulator—a lot of work to do to make sure that it is all done properly.
The next bit is the whole IP supervision process. We now have the situation where, at this moment in time, there are not enough qualified independent prescribers in the community pharmacy setting to supervise newly qualified IPs as part of their training. That is going to be a really big quandary. It is a circle we have to square. It will be a big challenge for the sector to make sure that it is in place.
The final thing on community pharmacy is that, if you look at GP practice, they get funding to train their people. Community pharmacy does not. In an awful lot of situations our members are being told—we are being told this at the Pharmacy First service—“If you are a locum and you are not fully trained and up to speed by 1 February, don’t even bother coming here to work.” That is no way to motivate a workforce or to get people skilled up or trained up. Yet in other sectors, particularly in the land of GP practice, you have budgets for training. You have budgets for infrastructure changes and improvements. It does not happen in the community pharmacy setting, and that needs to change.
Q117 Rachael Maskell: Nicola, do you have anything to add to that?
Nicola Stockmann: Absolutely, yes. Pharmacy technicians, year on year, are actually growing in number. That is really promising given the wider picture and pressures that we have. In December 2023, we had 25,768 registered pharmacy technicians, which is amazing. We are seeing the professional recognition, but what we need is support for continued professional development. We need the space to be able to learn. That is how you are going to continue to grow the workforce and retain those who are already there. That is across all sectors: hospital, community and everywhere that you would find pharmacy professionals. That is an emerging place as well.
There are cross-sector placements. At the very beginning you have training taking place in multiple areas. When they are qualified, you have pharmacy professionals who are experienced in a number of areas, again skilling them up for the future and maximising their time in training. It is all about the environment in which that takes place and the places where they operate post-qualification.
Rachael Maskell: Thank you very much.
Q118 Mrs Hamilton: My questions will be quick. Mark, my first question relates to the independent prescribers. You have talked a bit about it, but the question is whether there is a strategy that is going to come into play. How long will that take? How will it be implemented with all the different issues that you are talking about in the sector?
Mark Koziol: The independent prescribing possibility is an astonishingly exciting opportunity for anybody who is thinking of being a pharmacist or is actually a pharmacist. It is not new. We have had a slow build-up of independent prescribers throughout the whole of the UK. When you look at what has worked and what has not worked, in Scotland the vast majority of independent prescribers still do not use their independent prescribing qualification on a daily basis, or at all.
Q119 Mrs Hamilton: That is what happened in nursing. They did not use it because it was so narrow and so difficult to use that people gave up on it.
Mark Koziol: I think you have hit the nail on the head. The answer to your question is a strategic one. We do not just put in a community pharmacist with an IP qualification and make them a better community pharmacist. We give them an important strategic piece of work to do. Alongside the model that we were talking about earlier, if you have an independent prescriber who is using their IP qualifications every day to resolve patients’ medicines-related needs without having to send the patient to the doctor and without having to use the serious shortage protocols, and they are able to change the doses up or down and maybe even monitor the blood levels for whatever medication there is, that would mean that the IP would have to be using that qualification as part of their day job. If they were doing that, you would have a successful way forward for broadening independent prescribing to pharmacies and focusing on their unique skills.
Q120 Mrs Hamilton: Fantastic; thank you. Nicola, my question to you is on technicians. Going forward, if you were to give a recommendation to the Committee, what do you think we need to do to really put pharmacy technicians on the map?
Nicola Stockmann: That is the million-dollar question. I am so glad you asked it. It starts with enabling the profession. The question that has come out in our consultations is the first step for that. The patient group directions consultation has closed, and we are waiting on the outcome of that. It is going to be a massive enabler for the profession. We just need to make sure that the professional recognition is there. Supervision is the one that is out at the moment. Again, we need pharmacy technicians to be professionally recognised for the autonomous pharmacy profession that they are. They have so much potential. We want to make sure that policymakers and influencers recognise that. It could support capacity and patient safety. We are here and ready, but we need enablers around legislation to be able to do that.
The Medicines Act 1968 had a very different patient cohort that it was looking after. Now, we have an ageing population. We have more demand than ever. People are living longer, with more complex conditions. We are saying that pharmacy technicians are here and we can support that, but we need the enablers to be able to help us.
Q121 Mrs Hamilton: Thank you. My final question is to you, Duncan, as a regulator. I think primary care is definitely the vehicle to go forward. This morning, through all the questions that have been asked, I think it is difficult right now for it to go forward as smoothly as needs to happen. As a regulator, what are the two things that you think your area could do to help make the vehicle of pharmacy technicians get into the primary care space? Do you regulate them?
Duncan Rudkin: We certainly do, yes.
Q122 Mrs Hamilton: Everybody talks the talk, but because they are privately owned they are sometimes controlled by working closely with the GPs. They are quite independent bodies. Deborah, who spoke at the beginning, runs a completely private service. How can we put that into primary care?
Duncan Rudkin: That is a big question which goes in many ways beyond what I can help with. We, as the regulator, have a key role to play directly in the strategic piece around workforce competence and capability. We set and uphold the education standards.
In parallel with all of the work we are doing on initial education and training, and, equally, if not more importantly—dare I say it—we have a group looking at everything to do with how we and others assure the practice of people who are already on the register. That includes things like looking at revalidation and clinical governance in pharmacy. That is all key to the self-confidence of our professionals and to the confidence of the public and other health professionals. We need our doctors and nurses to be confident in what our pharmacy teams can do as well. That is part of it.
There is one thing which we have not talked about this morning, because I guess it is not within the scope of the workforce topic. If I could cheekily say, the other thing we would be flying a flag for is everything to do with integration of records. We know that is fundamental to safety and to effective, efficient and smart working, and not just in NHS organisations and NHS care providers. I would encourage us collectively to look hard at the question of how on earth we can integrate private provision in that as well. Where you have independent providers not able to connect with other records, there are clearly safety issues. We have seen that, sadly, in many coroner cases.
Mrs Hamilton: Thank you.
Chair: That concludes today’s session. We have heard from the Pharmacist Defence Association, the General Pharmaceutical Council and the Association of Pharmacy Technicians. We are very grateful to all of you for your time. We will continue our deliberations as we produce our report for Ministers. Thank you very much for coming in.