What does the future of pharmacy look like and how can the Government ensure this is realised?

Appropriate funding and funding mechanisms are needed to reflect the modern work of a community pharmacy, which has expanded beyond dispensing alone.

• In England, in an average week, 866,000 consultations are carried out to respond to patients’ symptoms and a further 20% seek advice about existing medical conditions. Around 83% of these are self-referrals with 17% being referred in from another health professional such as a GP or NHS 1111.
• Were pharmacies not there, it would result in approximately 619,000 additional GP appointments each week, or 95 appointments in each GP practice each week in England1, an increase on the estimated 492,000 total appointments, representing 65 per GP practice each week in 20212.

Pharmacists are trusted, clinical professionals at the heart of communities who can support patients with self-care for minor ailments and long-term conditions, taking pressure off other elements within the health care system.  However, they are currently facing financial pressures and a recruitment crisis. The proposed changes to the training for pharmacists and the resource dedicated to support that will also have a detrimental effect on achieving this vision. Action must be taken now to ensure future sustainability of community, bricks and mortar pharmacies nationwide to ensure equity of access, minimise health inequalities and ultimately save the system and society money in the longer term.

Not just a funding uplift but also the funding model needs to be adjusted. A model to consider is that in New Zealand, where there is a separate funding pot for services and dispensing, this is essential as currently in the UK service income and dispensing income come from the same pot that has, remained static in value since 2017, with reductions in value in the previous two years – static income during a period when national minimum wage alone has risen by 60%. (see later for more on funding).

THE NEW ZEALAND MODEL

Funding in New Zealand is covered by the New Zealand Community Pharmacy Services Agreement, remuneration for traditional dispensing services comes from one budget while distribution and handling deemed as ‘professional services’ are funded from another budget. 

Like in the UK, New Zealand Pharmacies receive remuneration for dispensing services “constituting a core dispensing fee per item ($4.43 NZD per initial item or $3.03 NZD per refill multiplied by a Relative Value Unit), medicine handling fee ($1.01 NZD) as well as a supply margin dependent on the cost of the medicine (3% margin for medicines costing less than $150 NZD; 4% margin for medicines costing more than $150 NZD).”3(para4)

New Zealand pharmacists also receive a monthly payment to reflect the professional services they provide encompassing the over the counter advice provided to the public, which in the UK is given for free and less than half of the time results in medication sale1 (on which margins often do not cover the cost of the pharmacist’s time).

Pharmacies in New Zealand receive a flat fee per month for Additional Professional Advisory Services, which is calculated using a complicated formula set out in the Community Pharmacy Services Agreement (CPSA).  The multiplier in the payment is higher if the patient holds a CSC or High Use Health Card (HUHC)[i] (the UK equivalent of these would be someone who receives free prescriptions and someone who has an NHS Prescription Prepayment Certificate) and higher still if they are from a Maori of Pacific Islander background[ii].

LONG TERM CONDITION MANAGEMENT POTENTIAL

There is also a long-term conditions service in New Zealand pharmacies, which includes a monthly payment that pharmacists can access when they have assessed patients and they meet certain criteria.  This is to help individuals with long term conditions like diabetes, asthma etc. manage their conditions. For each patient enrolled in the LTC program with a pharmacy, that pharmacy is paid $21 per month[iii].

For context in the UK at potential savings that could be realised by funding a service such as this, the 2021 PSNC pharmacy audit estimated that 13.6 million people a year seek guidance from their pharmacist on existing conditions management2. The importance of self-care and long term condition management is recognised as a key part of the NHS long term plan to ensure sustainability of the health service4. Management of long-term conditions is important in ensuring good health outcomes and avoiding hospitalisation – particularly for long term conditions like asthma and diabetes, which can be very costly to the NHS if they are not managed well. If we first look at diabetes as an example. It is estimated that 4.9 million people or 7.3% of the population have diabetes. It has been estimated that where diabetes is managed well, avoiding the need for inpatient care, cost savings to the NHS can be up to £2,130 per person[iv].  If we assume that, in line with the 7.3% of the adult population with diabetes, 7.3% of long-term condition guidance given in pharmacies relates to management of the condition, that represents 992,800 people per year.  If just 10% of these individuals attending a pharmacy for advice with their diabetes management avoid inpatient care, that represents a saving of up to £211 million.

Considering asthma as another potential example.  4.3 million adults receive treatment for asthma in the UK or 6.4% of the population5. Again, if we assume that, in line with the 6.4% of the adult population with asthma, 6.4% of long-term condition guidance given in pharmacies relates to asthma management, that represents 870,400 people.  The average cost of a hospital admission for asthma can be estimated at £9586[v], so if just 10% of those attending a pharmacy for advice with their asthma management avoid hospital admission, that saves £83.4 million.

OTHER CONSIDERATIONS: PHARMACY FIRST

The Pharmacy First service currently seen in Scotland and in development in the UK is a positive step, but the mechanism for payments to pharmacies for this service must be simple and appropriate, allowing patient self-referral with minimal bureaucracy.

MENTAL HEALTH AND WELL-BEING SUPPORT

Additionally, one must not forget the important role community pharmacies offer in supporting health and well-being more widely, as well as being a ‘safe space’ for victims of domestic abuse.  The Ask for ANI programme launched in Boots stores proved this during the pandemic.  Going a step further the Lifeguard Pharmacy research pilot currently taking place in Lincolnshire has found that by training staff members to identify the signs of suicide ideation, domestic abuse and mental health issues, equipped with appropriate local resources, they can intervene appropriately[vi].

As a result of the training Lifeguards received as part of the project, ‘Lifeguards’ are better able to talk to patients about wider areas of their lives and offer assistance. A total of fourteen case studies have been identified so far over this period covering suicide ideation, domestic abuse and wider health support. Control pharmacies noted no cases of intervention, supporting the assertion that better trained lifeguards provide a clear and valuable support service for populations, catching any issues earlier than they otherwise may be, if at all potentially avoiding suicides and domestic abuse incidents with their associated costs. The project has been running for 5 months as a pilot. The potential for hub sites across the county is being considered, as well as widening the service to encompass a greater range of information provision (which aligns well with the making every contact count programme in the NHS and the focus on social prescribing, self care and support). There is a cost to this Lifeguard service which is not ‘item based’ but rather availability based with a flat fee paid to each pharmacy and local oversight costs. The project is currently looking for an extension to continue data gathering and proof of concept in the county.

What are the challenges in pharmacy workforce recruitment, training and retention, and how might these best be addressed?

There are several areas which impact recruitment, training and retention, these have been outlined below:

PCN PHARMACY ROLES AND COMMUNITY PHARMACY ROLES EQUITABLE FUNDING

Pharmacy is facing a Workforce crisis and the number of pharmacists on the register is not a fair reflection of the pressures that community pharmacies are under. In a recent reply to a question from Taiwo Owatemi around pharmacy workforce, the Health Minister Stephen Barclay noted that there were 20,000 more pharmacist on the register than in 2010.  However, this does not translate into more full-time pharmacists working in communities. 

Firstly, since 2010, many new roles have been created across primary care networks (PCNs), a good thing but it means the resource is spread more thinly.  Secondly, many pharmacists now choose to have portfolio careers, working only part time as a front-line pharmacist and thirdly, those who are no longer practising regularly as a pharmacist will still maintain their registration as it is very difficult to reregister once you stop being registered as a pharmacist.  Not all registered pharmacists will therefore be working as front-line clinicians.

In May 2023, the Company Chemists’ Association estimated that 8,800 pharmacists had been recruited into wider primary care ARRS roles since March 2019. The GPhC register shows that the number of pharmacists added to the register between May 2019 and May 2022 totalled 4,515, meaning there are in excess of 4,000 fewer pharmacists potentially able or willing to work in community pharmacies than there were in 2019[vii]. The PCN roles receive government funding support, whereas the community pharmacies have seen a 35% funding cut in real terms since 2015, making it difficult to compete with PCN roles in attracting staff. This inequality needs to be balanced with an increase in the pharmacy budget.

PLACEMENT FUNDING AND COURSE STRUCTURE – CHANGES TO REGULATIONS TO ALLOW THE SERVICE DELIVERY BY STUDENT PHARMACISTS UNDER SUPERVISION

Universities are increasingly asking pharmacies to take on placement students with little or no financial reward. Taking pharmacy students for placements is not compulsory and we risk companies no agreeing to do this, so students cannot complete the patient facing and practical elements of their degree programme.  Prescribed, 13-week placements for students are not sustainable for example, or specifying a day of the week that students must attend for an extended period. Pharmacies take on placement students for altruistic reasons and it often costs them to do so, as time spent with a student is not time they can deliver paid services. If the regulations were changed to allow undergraduate pharmacy students to deliver simple services such as blood pressure checks and flu jabs when supervised by the pharmacist, for which the pharmacy contractor could claim payment, this would be beneficial for the student, the contractor and the NHS – importantly costing the NHS no additional resource and upskilling future pharmacists while improving their confidence at the same time.

FOUNDATION TRAINING YEAR

From an employer perspective, the changes to current undergraduate courses place significant burdens to support placements; these are somewhat funded but not at medical tariff rates and so can prove costly for providers and challenging for HEIs to organise and manage. From what we know at this stage, the planned changes to the Foundation Training Year also present significant concerns in the future too; multi-sector placements and IP training all require careful co-ordination, implementation and management, all with NHS funding that does not cover the required trainee’s salary, ignoring the significant administrative and training burden that such placements add. This may cause some organisations to withdraw from supporting training (I have been advised by the Local Pharmaceutical Committee that they have already seen several community pharmacy organisations cease to offer foundation training places within the current approach, and the future methods place an even greater cost and time burden on employers).

BURSARY FUNDING FOR PHARMACY STUDENTS

Finally, unlike other healthcare students such as nurses and allied healthcare professionals, who often qualify for a £5,000 bursary as a minimum, pharmacy students do not qualify for any support from the NHS Learning Support Fund and receive no NHS training bursary. Consideration should be given to adding pharmacy students to the LSF funding. The government is keen to ensure pharmacists are recognised as an integral part of the front-line primary care workforce and encourage people into the profession to alleviate the current workforce crisis. If Ministers truly value the role of pharmacists within our integrated care systems, with current policy urging patients to see their pharmacists for minor ailments to support the system, then surely students should be adequately supported financially.  Making pharmacy the least well financially supported option in health care professions will not solve the current workforce crisis and assist the DHSC in their aim to increase the number of pharmacists trained in the country.

ESSENTIAL VS ADVANCED SERVICES AND LOCUMS

Locums will often only deliver essential services – this can cause issues. I do not know what the solution is here, but the more services that are essential, the easier it is to deliver them universally.  Additionally, provision should be made in service level agreements for advanced services to be delivered ‘the majority of the time’ rather than at all times.  There have been occasions locally when the choice was for a pharmacy to close its doors or accept a locum who was unable to offer an extended service. It is far better for the pharmacy to open and deliver essential services rather than shut in case they get a referral for an extended service. 

To what extent are digital systems used in pharmacy sufficiently interoperable with those in general practice and hospitals?

Barely.  This is a real barrier to integration. Seamless integration between GPs and hospitals to allow referral into systems like PharmOutcomes and Cegedim amongst others is essential.  APIs must be developed prior to service launch to ensure efficient processing of payments due to pharmacies. Large volumes of DMS referrals can simply not be handled using nhs.net mail referral.

Referral via nhs.net mail is not appropriate in a busy pharmacy environment for several reasons. Firstly, pharmacists are not sitting at a computer all day reading emails, the store email address has to be logged into.  Secondly, locums do not have access to store email accounts but they usually have access to the store pharmacy system, for example, PharmOutcomes.  This means they are relying on other team members to check for service referrals – this is not practicable in a busy pharmacy. Finally, the nhs.net mail contains many non-patient communications and in a time pressured environment it is difficult to identify referrals – whereas when they arrive in pharmacy systems such as PharmOutcomes, they are shown in a queue to be done.

It also seems inequitable that pharmacies delivering services operate on a ‘provider pays’ model, with each pharmacy paying a fee for receiving a referral electronically whilst GP practices are provided with support for software systems, telephone systems etc. If pharmacy is seen as integral to primary care access, then the priority for funding should be equitable.

What innovations could have the biggest impact on pharmacy services and why?

Funding uplift – better structured to support the pharmacist as a clinician utilising their skills treating minor ailments. See answers to the other sections around funding for additional information.

Better IT interconnectivity – understanding that email referrals are not practicable in a busy pharmacy environment

To what extent are funding arrangements for community pharmacy fit for purpose?

Funding arrangement for community pharmacy are not fit for purpose in a changed world where community pharmacy is such an integral part of the primary care landscape.

Pharmacies have been working from a flat budget since 2017/18, with no increase to cover the inflationary pressures they face. In fact, the budget was reduced from £2.8 billion in 2015/16, to £2.687 billion in 2016/17, and £2.592 in 2017/18[viii]. During the period since 2017 pharmacies have taken on delivery of many new services, and funding for this increased activity and workload comes from the same ‘pot’ – the Global Sum, which has remained static in value representing a 35% decrease in real terms in the budget; notably, within the same time period the Department of Health and Social Care Budget increased by 28% (excluding extra Covid funding) and salaries for Members of Parliament increased by more than 12%.  From a consideration of costs for community pharmacy contractors, the National Living Wage alone has risen from £6.50 per hour in 2015 to £10.42 per hour today – a rise of over 60%.

As the year progresses and more services are delivered and funded the pot is depleted, leading to potentially very low incomes for pharmacies in the autumn/winter period – as dispensing payments are reduced to stay within budget and holds or caps are put on service numbers – the very period when there is the most pressure in the health system.  This does not make sense.

The government’s announcement of £645 million over two years, (equating to £322.5 million per annum) for community pharmacy is welcomed but there is little detail on how and when this will be paid.  We understand that a proportion of this budget will be spent on IT interface development, which will benefit the system including pharmacies, but will reduce the cash injection available to pharmacies. With latest estimates in the pharmacy sector from the Community Chemists Association believing annual funding is £750 million short, this money represents less than half of the necessary funding to ensure stability in the sector. No income will likely be received until December (on 24th May at PMQs the prime minister noted funding would be distributed by the end of the year).

Whilst the move to a service-based model for community is the appropriate direction of travel, the lack of funding to facilitate this has caused harm to the sector. Currently, both service and dispensing income come from the same pot that has, as noted above, remained static in value since 2017. 

Much of the additional income available now (and it appears in future) is linked to inward referral into community pharmacies from other providers, so pharmacies that do not receive referrals and therefore cannot offer these services, for no fault of their own, are receiving less for their core dispensing work while costs are spiralling, with no meaningful way of increasing their income. Even when pharmacies that are able to offer services, they are perversely reducing the amount of dispensing income pharmacies receive as all money comes from the same, fixed ‘pot’. In layman’s terms, this is comparable to offering to pay a staff member overtime for doing extra hours, but the more overtime they do the less basic salary they get paid. This is counterproductive and does not offer a sound business model, hence many contractors are now reassessing their pharmacy sites and/or access times. For example provision of the Community Pharmacy Consultation Service (CPCS), with referrals from GPs and NHS111, the Discharge Medicines Service, and provision of hypertension and contraceptive services is limited, which for patients in a rural county like Lincolnshire, is limited, increasing health inequalities. The Discharge Medicine Service, which requires referrals into community pharmacy from hospitals, is not currently supported by the main secondary care provider in Lincolnshire and so pharmacy contractors are ‘missing out’ on their share of the pot for DMS, and patient care is being compromised.  Additionally, around one third of GPs in Lincolnshire are dispensing GPs, with 25% having 60% or more dispensing patients. GP dispensed patients cannot benefit from DMS and having a high level of dispensing patients has been found, in some areas, to make GPs reluctant to engage in referral of patients to pharmacies for other services, as they fear losing income from both dispensing and services such as flu vaccines.

I have outlined some solutions in the answer to the first question in this response, but the budget must be increased to ensure a stable pharmacy sector moving forwards.

What factors cause medicine shortages and how might these be addressed in future?

CONTRIBUTORY FACTORS

• The low price the NHS pays for drugs impacts on availability as drug companies choose to sell to higher priced buyers when there is a shortage.

• The decision by government some years ago to allow single wholesalers for specific drugs has caused issues as well, especially when the wholesaler owns a chain of pharmacies.

• Import complexities as a result of Brexit

Potential solutions:

FLEXIBILITY IN GP DRUG BUDGETS IN CERTAIN CIRCUMSTANCES & SERIOUS SHORTAGE PROTOCOLS

Changes by former CCGs to ‘swap everyone to’ a cheaper drug etc. This causes pressure on supply.  Additional SSPs would make life easier for the pharmacy and the GP. Flexibility in GP drugs budgets when alternative drugs need to be supplied would improve relationships between GPs and pharmacies – GPs are reluctant to approve alternative drug provision when the cost is higher even if this is the only item that the pharmacy can obtain.

TAX INCENTIVES FOR UK DRUG PRODUCTION AND SUPPLY

It would be good for the government to provide tax incentives to produce drugs in the UK and supply them to the NHS – this would need to be at a level where it is better for the company to produce and supply drugs in the UK rather than produce in the UK and supply to overseas buyers where the price for a specific drug may be higher.

To what extent does community pharmacy have the resource and capacity to realise the ambitions in DHSC's Primary Care Recovery Plan?

More funding is needed. Pharmacy is on its knees, without this, pharmacies will continue to reduce opening hours and some, as we have seen with the recent closure of 237 Lloyds pharmacies in Sainsburys, will pull out of the pharmacy marker altogether.

Pharmacies need a cash injection now and simple service referral mechanisms to realise their potential in the Primary Care Recovery Plan. See responses to other sections for more detail about funding shortfall.

Are there the right number of community pharmacies in the right places, and how can we ensure that is the case across the country?

This is a complex question with no easy answer. The decision to allow 100 hour pharmacies to open anywhere several years ago without an identified need has caused negative financial impacts to previously stable pharmacy businesses – some of which have closed as a result. Now we see 100 hour contracts reducing to 72 hours and or being closed with the owners buying 40 hour contract premises.

Unfortunately, relying on market forces to dictate which pharmacies are viable – a decision made a result of reports completed long before the move to integrated care systems and the more holistic care landscape we see now – has led to those pharmacies in areas in most need closing as they are the least independently viable financially. 

Most pharmacies rely on the NHS for the majority of their income I believe the range is 68-85% of pharmacies income comes from the NHS across the UK.  In affluent areas they can offer private services which will be taken up by wealthier resident but in poor areas and rural areas this is not viable.  I know of only one independent pharmacy that is entirely private and this is in the New Forest – a very affluent area.  To give some local knowledge from my area, rural Lincolnshire, coastal deprived areas like Mablethorpe and inner city deprived areas of Lincoln cannot sustain a pharmacy that does not receive sufficient NHS funding as they will simply not be able to sell private services.

Again, this all boils down to funding and they structure of payments. If we truly want pharmacy to be part of an integrated health system we need to fund it appropriately – this will bring savings downstream.  Even the pharmacies we have now are reducing their supplementary hours.  The argument of ministers has been ‘a new pharmacy can open’ but private organisations will not open loss-making ventures.  We have seen with the recent Lloyds closures that some organisations are reconsidering their presence in the pharmacy sector. In Lincolnshire Lloyds Alford Pharmacy has had a buyer pull out and struggles to stay open due to staffing issues – this is the only pharmacy in the local area for several miles with an ageing population with multiple long term conditions.  This is not an area where money can be made from private services.  The PhAS scheme that is supposed to support these pharmacies is not fit for purpose.  The removal of transitional payments entirely in February 2023 has exacerbated the already dire financial situation in pharmacies like these.

How to move forward? Again, this requires a change in mindset of how funding is provided and an increase in the base funding as well as its structure.  I have gone into this in more detail in my first answer.  Support for pharmacies that are essential for populations – such as Spilsby, Wainfleet All Saints and Alford in my area – but are difficult to make financially viable due to the high prevalence of dispensing GPs (which lowers dispensing income available to pharmacies) and high levels of older less affluent populations and/or deprivation.

To what extent are commissioning arrangements for community pharmacy fit for purpose?

Change is needed. IT needs to be in place before services are launched and the remuneration for services both at set up and ongoing needs to be appropriate and take account of overheads and on costs. Referral via nhs.net mail is not appropriate – an integrated referral system to link with pharmacy IT systems is necessary and the API to allow automated claims must be in place. The budget for new services needs to come from a different pot to the dispensing budget otherwise pharmacies are being paid less for doing more work.

Nationally commissioned services are better than local services in many cases. If pharmacies have branches across ICS boundaries – even independents but especially the large multiples – dealing with differed SLAs and PGDs is complicated.  A single national service spec is easier to implement.

The service payments often do not cover the cost of delivery even with set up payments.  Pharmacies have overheads, none of which are paid by the NHS unlike GPs who have capital expenditure programmes and rent paid.

Locally commissioners do not have the budget to commission local services.