Written evidence submitted by Matthew Jones, University of Bath (PHA0017)

Introduction

This submission summarises the findings of a PhD research project entitled ‘The future of community pharmacy in England: policy, stakeholder and public perspectives’. This was carried out in the Department of Life Sciences at the University of Bath from 2017-2021. The results of this project are currently under peer review for publication in scientific journals, so are not yet fully in the public domain.

The University of Bath is a research- and teaching-intensive university that is highly ranked in independent league tables. It is the current Times and Sunday Times ‘University of the Year’.

This PhD was completed by Dr Evgenia Paloumpia, under the supervision of Dr Matthew Jones, Dr Piotr Ozieranski and Professor Margaret Watson.

This submission consists of three components:

• The text of a policy briefing based on the findings of this project, which will be presented at a reception in Parliament on Wednesday 12th July 2023. This includes links to a peer reviewed paper based on the first phase of the project that was published on 28th June 2023, and to the PhD thesis, which gives a detailed account of the whole project.
• The abstract of a paper entitled ‘Professional stakeholders’ expectations for the future of community pharmacy practice in England: a qualitative study’ which is currently under peer review ahead of potential publication in a scientific journal.
• The abstract of a paper entitled ‘Public stakeholders’ expectations for the future of community pharmacy practice in England: a qualitative study’ which is currently under peer review ahead of potential publication in a scientific journal.

aThe views expressed in this submission are purely those of the author. They do not necessarily reflect the views or official positions of the European Commission and the ERC Executive Agency.

The future of community pharmacy in England: policy, stakeholder and public perspectives

A policy briefing

There are over 11,000 community pharmacies (or ‘chemists’) in England, found on high streets and in supermarkets, shopping centres and health centres. They are retail outlets that also have qualified pharmacists supplying medication and providing medicines-related and public health services without appointments.

This project

This research programme explored opinions on the future of community pharmacy in England. We analysed 25 community pharmacy policies published by the Department of Health, the NHS and the pharmacy profession between 2008 and 2017, considering the policymaking process and policy content. In 2018-19, we also spoke to 36 community pharmacy stakeholders from a wide range of backgrounds, including:

Why now?

Despite the substantial contribution that community pharmacies make to the NHS throughout England, particularly during the Covid-19 pandemic, the sector is experiencing sustained underfunding. There has been a 25% real terms cut in funding since 2015, leading to a 5% reduction in community pharmacies in England since 20188. Over 500 further pharmacies were threatened with closure in the first half of 20239 10 and several thousand more are likely to close in the next few years8. This would be a threat to the safe supply of medicines and increase health inequalities.

The current situation

• There is widespread recognition of the need to make more effective use of community pharmacy.
• Patients value their community pharmacies and their staff, but are concerned about their workload and working environment, as well as the risk of permanent pharmacy closures.
• This was reflected by community pharmacists, who feel demotivated, insecure and undervalued.
• Current relationships between community pharmacies and general practices can be competitive rather than collaborative.

What is the future for community pharmacy?

We found many areas of consensus between the policies and stakeholders regarding the future:

• A ‘hub and spoke’ model should be used to supply medicines, while ensuring that patients continue to have the opportunity for face-to-face contact with a pharmacist when they collect their medicines.
• Pharmacists should use the time released by automated dispensing to provide more nationally commissioned services directly to patients.
• These should focus on relieving pressure on GP surgeries, such as long-term condition management, urgent care advice and public health (including vaccination).

What will support these changes?

• Additional training for community pharmacy staff, especially independent prescribing qualification for pharmacists.
• Greater use of the skills of pharmacy technicians.
• Systems to enable closer working with general practice, in particular the ability for community pharmacists to read and add information to patients’ health records.
• New services should be piloted and then commissioned nationally to ensure consistent and equitable provision. This will lead to patient familiarity, thus encouraging uptake.
• Increased remuneration based on service quality.
• Professional leadership and representation for community pharmacy that is stronger, more unified, and more proactive than at present.

Areas for development

We found many topics where there was not consensus between policies and stakeholders, suggesting that further work is required:

• Policymaking by professional bodies was less transparent, with less stakeholder involvement than Department of Health and NHS policies. This may reduce credibility and explain why professional policies did not strongly influence state policies.
• Department of Health and NHS policies frequently identified cancer, mental health, health inequalities, quality of care, and generation and use of research evidence as key priorities, but these were not often discussed in policies from professional bodies.
• Many community pharmacies need to provide more space and greater privacy.

Recommendations for the Department of Health and Social Care and NHS England

• Increase community pharmacy funding to avoid damaging closures and diminution of quality.
• Reform the NHS community pharmacy contract to reward quality, not dispensing volume.
• Pilot and then nationally commission successful new community pharmacy services for long-term conditions, urgent care and public health (including vaccination).
• Facilitate ‘hub and spoke dispensing’, while ensuring that all patients can quickly access urgent medicines and have face-to-face contact with a pharmacist whenever they need it.
• Ensure funding and provision of training for all community pharmacy staff to provide new services, especially independent prescribing. Include support to release staff to study during pharmacy opening hours.
• Provide community pharmacists with read and write access to patient health records, with appropriate safeguards aligned to patient preferences.
• Align NHS contracts for GPs and community pharmacies to encourage collaboration, not competition.

Recommendations for the pharmacy profession and employers

• Take urgent action to better support the community pharmacy workforce to feel motivated, secure and valued.
• Ensure that professional leadership and representation for community pharmacy is stronger, and more proactive than at present. Give a united message to multiple audiences such as the public, NHS and Government.
• Develop policies with greater transparency and stakeholder involvement, to ensure they focus on patient and NHS need.
• Ensure community pharmacy policies and culture prioritise the quality of care.
• Generate more evidence for the safety and effectiveness of community pharmacy services.
• Develop more community pharmacy services for mental health, cancer and health inequalities.
• Ensure funding and provision of training for all community pharmacy staff to provide new services, especially independent prescribing. Include support to release staff to study during pharmacy opening hours.
• Ensure all community pharmacies have sufficient high-quality, private space for patient services.

Published reports

The findings of the policy review have recently been peer reviewed and published in Exploratory Research in Clinical and Social Pharmacy11. The full report of the project is also available online12. Further reports of focus groups and interviews with public and professional stakeholders are currently undergoing peer review and are expected to be published later in 2023 under the following titles:

• “Professional stakeholders’ expectations for the future of community pharmacy practice in England: a qualitative study.”
• “Public stakeholders’ expectations for the future of community pharmacy practice in England: a qualitative study.”

aThe views expressed in this briefing are purely those of the author. They do not necessarily reflect the views or official positions of the European Commission and the ERC Executive Agency.

References

1. NHS England. Improving health and patient care through community pharmacy - evidence resource pack. London, UK, 2013.

2. Pharmaceutical Services Negotiating Committee. About community pharmacy, 2020. Available from: https://psnc.org.uk/psncs-work/about-community-pharmacy/. Accessed 7 November 2020.

3. Todd A, Copeland A, Husband A, et al. The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England. BMJ Open 2014;4(8):e005764. doi: 10.1136/bmjopen-2014-005764.

4. Evans CD, Watson E, Eurich DT, et al. Diabetes and cardiovascular disease interventions by community pharmacists: A systematic review. Ann Pharmacother 2011;45:615-28. doi: 10.1345/aph.1P615.

5. Watson M, Holland R, Ferguson J, et al. Community pharmacy management of minor illness (MINA study). London, UK: Pharmacy Research UK, 2014. Available from: https://pharmacyresearchuk.org/wp-content/uploads/2014/01/MINA-Study-Final-Report.pdf.

6. Thomson K, Hillier-Brown F, Walton N, et al. The effects of community pharmacy-delivered public health interventions on population health and health inequalities: A review of reviews. Prev Med 2019;124:98-109. doi: 10.1016/j.ypmed.2019.04.003.

7. Royal College of Emergency Medicine, Royal College of General Practitioners, Royal College of Physicians, et al. Rebuilding the NHS: better medical pathways for acute care. London, UK, 2022. Available from: https://www.rcplondon.ac.uk/projects/outputs/rebuilding-nhs-better-medical-pathways-acute-care-2022. Accessed 31st January 2023.

8. Taylor D, Kanavos P. Protecting UK public interests in NHS community pharmacy: National Pharmacy Association, 2022.

9. Sayburn A. Supermarket pharmacy closures: a watershed moment? Pharm J 2023;310(7970). doi: 10.1211/PJ.2023.1.175112.

10. Wickware C. Boots to close 300 pharmacies as part of cost-cutting plan. Pharm J 2023;310(7974). doi: 10.1211/PJ.2023.1.189754.

11. Paloumpi E, Ozieranski P, Watson MC, et al. Professional and governmental policy on community pharmacy: a 10-year policy review and comparative analysis (2008-2017). Explor Res Clin Soc Pharm 2023; Accepted, in press. doi: 10.1016/j.rcsop.2023.100298.

12. Paloumpi E. The future of community pharmacy in England: policy, stakeholder and public perspectives [PhD thesis]. University of Bath, 2022. Available from: https://researchportal.bath.ac.uk/en/studentTheses/the-future-of-community-pharmacy-in-england-policy-stakeholder-an.

Abstract of ‘Professional stakeholders’ expectations for the future of community pharmacy practice in England: a qualitative study’

Objectives: To explore the views of professional stakeholders on the future of community pharmacy services in England. Specific objectives related to expectations of how community pharmacy services will be provided by 2030 and factors that will influence this.

Design: Qualitative, using semi-structured interviews in person or via telephone/Skype. The topic guide was informed by a recent policy review that used the Walt and Gilson policy framework. Transcripts were analysed using inductive thematic analysis.

Setting: England

Participants: External stakeholders were representatives of non-pharmacy organisations, including policymakers, commissioners and representatives of healthcare professions. Internal stakeholders were community pharmacists or pharmacy organisations representatives. Interviewees were identified using stakeholder mapping

Results:  In total, 25 interviews were completed (7 external stakeholders and 18 internal stakeholders, of which 10 were community pharmacists). Community pharmacy was recognised as having a key role in expanding health system capacity (“…pharmacy is the obvious person to take on those roles…”), particularly for long-term condition management (e.g. adherence, reducing polypharmacy, monitoring), urgent care (e.g. minor illnesses) and public health (including mental health). For these contributions to be developed and optimised, greater integration and collaboration with general practices will be needed (“…there is no room for isolationism in pharmacy anymore…”), as well as use of technology in a patient-centred way and full access to health records. These changes will require workforce development together with appropriate commissioning and contractual arrangements. Community pharmacy is currently undervalued (“…the complete misunderstanding by senior Government officials is very scary”) and recent investment in general practice pharmacists rather than community pharmacy was seen as a missed opportunity.

Conclusions: Community pharmacy as a sector could and should be developed to increase health service capacity to address its current challenges. Numerous modifications are required from a range of stakeholders to create the environment in which these changes can occur.

Abstract of ‘Public stakeholders’ expectations for the future of community pharmacy practice in England: a qualitative study’

Objective: To explore public perceptions of current and future provision of community pharmacy services in England.

Methods: Qualitative, reconvened focus groups were conducted with community pharmacy users. An initial focus group explored preliminary views. Participants were then given an evidence brief describing community pharmacy prior to a reconvened focus group two weeks later. Transcripts were analysed using inductive thematic analysis.

Key findings: Eleven individuals participated across two reconvened focus groups. Participants valued community pharmacies and staff, but lacked awareness of their services and roles: “…I don’t think the general public is aware of all of this…it gives you a very different perspective”. Urgent care and long-term conditions management were identified as suitable for future development, facilitated by training, closer collaboration with general practices, shared access to health records, and premises with more space and confidentiality: “I still think of it as a retail space more than as a health service”. Concerns were expressed about working conditions in community pharmacy and unplanned closures: “doesn’t sound like a great place to work”. Participants anticipated greater use of technology but did not want this to replace face-to-face contact with pharmacy staff: “I am not saying it’s inaccurate, it is so remote and impersonal”.

Conclusions: The public would value a greater role for community pharmacy in addressing the challenges currently faced by the health service in England, provided that their concerns on a range of issues are addressed.

July 2023