Written evidence submitted by the Department of Health and Social Care (PHA0018)
Community pharmacies are a key part of the NHS. The Community Pharmacy Contractual Framework (CPCF) 2019-24 five-year sets out a clear joint vision from DHSC, NHSE England and Community Pharmacy England. The ambition set out in this vision is for community pharmacy to be more integrated in the NHS, delivering more clinical services and becoming the first point of call for minor illness.
Good progress has been made so far on implementing the five-year deal. A range of new services have been introduced. NHS111, GPs and Urgent and Emergency Care (UEC) can refer patients to a community pharmacy for a minor illness consultation and NHS111 and UEC can also refer patients for an urgent medicine supply. Hospitals can refer recently discharged patients to a community pharmacy for extra support with their new medication which increases medicine adherence and prevents rehospitalisation. Most pharmacies also offer blood pressure checks to support identification of people with high blood pressure. Under the New Medicines Service, year-on year pharmacies are providing extra support to more patients newly prescribed certain medicines which increases adherence and decreases preventable side effects of medicines. In April this year, a contraception service was launched in community pharmacy to enable women to see their pharmacist instead of their GP for their contraception.
In addition, community pharmacies are playing a growing role in our Covid-19 and flu vaccination programmes. In the last flu season, they vaccinated more than 5 million people against flu, more than ever before.
We want to go further with community pharmacy and that is why they are central to the Delivery plan for recovering access to primary care that was published on 9 May. The Delivery plan proposes to invest up to £645 million to support a Pharmacy First service which will include expanded treatment options for seven common conditions, including earache, sore throat and urinary tract infections. This will allow community pharmacists to assess patients and supply certain prescription-only medicines without a prescription from a GP. Part of the investment will go into the existing contraception and blood pressure checks services to enable community pharmacies to provide more women with contraception and do more blood pressure checks.
We are consulting with Community Pharmacy England, the representative body of pharmacy contractors in England, about the pharmacy proposals in the Delivery plan with a view to introducing Pharmacy First by the end of the year.
Many of these services have been piloted through the Pharmacy Integration fund which was set up to support the development and implementation of services in community pharmacy. NHS England are about to launch a range of pathfinder pilots to explore how pharmacist prescribers in community pharmacy can best support the wider system.
NHS England (formerly Health Education England) conduct an annual survey of the community pharmacy workforce to inform future service planning and investment decisions. NHS England are currently analysing data gathered from the 2022 survey and the results will be published shortly.
In 2021, there were 27,406 pharmacists working in community pharmacy, filling 20,489 full-time equivalent posts. Across all sectors, the number of registered pharmacists in England has increased by 82% since 2010 (from 28,984 to 52,780 (31 March 2023)). That’s nearly 24,000 more pharmacists registered in England than in 2010.
The number of pharmacy training places annually is uncapped. In England, each year around 2,500 pharmacists enter pre-registration training and the net increase in pharmacists practicing across all sectors has increased by around 1,400 per year since 2016. The NHS Long-term Workforce Plan recognises that education and training places for pharmacists (that is the number of students starting an Mpharm degree) are estimated to need to grow by 31–55% to meet the demand for pharmacy services, reaching 4,359–5,174 by 2032/33. The number of pharmacy technicians will also grow in future years.
Pharmacists are highly qualified essential members of the healthcare team. From 2026, all pharmacists will qualify with a prescribing qualification. To upskill the existing workforce and improve career satisfaction, NHS England is introducing a range of measures to accelerate the expansion of prescribing and broader clinical skills. This will be achieved through investment from the Pharmacy Integration Programme. As part of a £15.9 million, three-year programme of education and training, 3,000 independent prescribing places and 10,000 module places for clinical examination skills training for community pharmacists have been funded.
The Delivery plan for recovering access to primary care sets out that we will progress work to clarify the roles of pharmacy professionals in legislation and enable a better use of skill mix in pharmacy teams. This will enable pharmacists to use their valuable skills where they most benefit the NHS and provide for development and new roles for other pharmacy team members. This sits alongside work, to enable pharmacy technicians to administer and supply medicines under patient group directions. This expansion is underpinned by HM Revenue and Customs (HMRC) confirmation that services delivered by registered pharmacy technicians are exempt from VAT. We are revising NHS service specifications to support delivery by pharmacy technicians, recognising their valuable role in clinical service delivery. HMRC have also made changes to VAT legislation that make services supervised by pharamcy professionals exempt from VAT which supports delivery of services in pharmacy by non-registered staff as long at hey are supervised.
These IT improvements will improve existing and future services; for example, by allowing GP patient records to be updated following supply of oral contraception or a blood pressure consultation in community pharmacy.
The Booking and Referral Standard (BaRS) is an interoperability standard for healthcare IT systems that enables booking and referral information to be sent between NHS service providers quickly, safely and in a format that is useful to clinicians. This will support an integrated referral message from general practice into a community pharmacy as set out above. This will provide the foundations to support additional development in the future including between hospitals and community pharmacies.
In addition to interoperable digital system (see question 3), we want to give community pharmacy contractors more choice about how they deploy staff and release pharmacists’ time for more patient-facing services. Pharmacists and pharmacy technicians are experts in medicines, and from 2026 updated training standards will ensure all newly qualified pharmacists are independent prescribers. We want to better use these clinical skills to benefit patients. As set out in the Delivery Plan for recovering access we will take action to support this including:
The Community Pharmacy Contractual Framework 2019-2024 five-year deal commits £2.592 billion per year to community pharmacy. This funding is made up of fees and allowances (£1.792 billion) and medicine margin (£800 million), which is the difference between the price pharmacies source medicines at and the price they are reimbursed by the NHS. In September 2022, we announced a one-off investment of £100 million in the sector across 2022/23 and 2023/24. In addition, the Delivery plan, announced on 9 May 2023, proposes to invest up to £645 million across 2023/24 and 2024/25.
As part of the CPCF agreement for years 4 (2022/23) and year 5 (2023/24), DHSC, NHS England agreed to work with CPE and pharmacy contractors to further our understanding of the sector using more comprehensive data and engage in discussions on issues affecting the future of the community pharmacy sector. As part of that, NHS England will commission an economic analysis of NHS pharmaceutical services through an independent review, using data provided by pharmacy contractors, and will work with CPE on the review. This review will help inform the negotiation of the future contractual framework for community pharmacy.
The production of medicines is complex and highly regulated, and materials and processes must meet rigorous safety and quality standards. Medicine supply problems can occur for a number of reasons: due to manufacturing difficulties, regulatory problems, problems with the supply of raw materials, sudden demand spikes or from issues which are related to the distribution of the product.
We work closely with suppliers, NHS England, the Medicines and Healthcare products Regulatory Agency (MHRA), the devolved governments and other stakeholders to ensure patients continue to have access to the treatments they need.
The Department routinely shares information about medicine supply issues directly with the NHS so they can put management plans in place to mitigate the risk of the shortage impacting patients. Medicine Supply Notifications (MSNs) are used to provide advice to healthcare professionals on how medicines should be managed when there is a shortage.
We are working closely with the MHRA, NHS England, the Office for Life Sciences, other government departments, the devolved governments, industry and academia on a range of measures to strengthen UK medicine supply resilience. This work builds on existing analysis of medical product supply chains as part of the cross-Government focus on critical supply chains resilience which was established in 2020.
The Delivery plan announced on 9 May 2023 proposes to invest up to £645 million to support a Pharmacy First service and expansion of the existing contraception and blood pressure checks services. We have seen in the past that when funding is available, community pharmacy is able to scale up to deliver. For example, during the Covid-19 pandemic they rapidly set up a medicines’ delivery service and a lateral flow test service. In recent year community pharmacies have significantly increased their share of flu vaccinations. Nevertheless, there are workforce pressures on community pharmacies with both pharmacists and pharmacy technicians in high demand which we are addressing (see question 2).
Access to community pharmacies is generally good with 80 percent of people living within 20 minutes walking of a community pharmacy and twice as many pharmacies in more deprived areas.
Community pharmacies are not directly commissioned. Instead, Integrated Care Boards operate a market entry system that controls which pharmacies enter the pharmaceutical list. All pharmacies on that list must provide essential NHS pharmaceutical services and may provide advance services such as blood pressure checks or the contraception service. The market entry system has been designed to ensure that the provision of pharmaceutical services meets the needs of local populations.
Every three years, Local Authorities Health and Wellbeing Boards develop and publish Pharmaceutical Needs Assessments (PNAs) for their areas. A pharmacy applying to an ICB to enter the pharmaceutical list must demonstrate how opening a new pharmacy would meet a current or future need for pharmaceutical services as identified in the PNA. Alternatively, they could apply to deliver benefits unforeseen in the PNA that would nevertheless secure improvements and better access to pharmaceutical services. ICBs must take account of the PNAs when making decision on applications. The latest PNA assessments were published in October 2022 and most of these assessments conclude there are no gaps in the provision of pharmaceutical services in their local areas.
As set out under question 8, community pharmacies are not directly commissioned but entry to the market is regulated by ICBs based on PNAs. Once on the NHS pharmaceutical list, community pharmacies must provide essential pharmaceutical services. Those include dispensing of medicines and medical appliances, disposal of unwanted medicines, advising patients on self-care and healthy living. Pharmacies can choose to provide advanced pharmaceutical services. Those services are nationally set and specified and include flu vaccination, the New Medicine Service, the Community Pharmacist Consultation Service, the Blood Pressure Checks Service, the Smoking Cessation Service and the Pharmacy Contraception Service. In addition, ICBs can commission local enhanced pharmaceutical services from specific pharmacies to meet the needs of their local populations such as medicines delivery, minor ailment schemes or palliative care. Outside of the NHS pharmaceutical framework, local authorities also commission services from community pharmacies including for example emergency hormonal contraception, sexual health services, needle and syringe exchange services or smoking cessation services.
As set out under question 8, access to community pharmacies is generally good with 80 percent of people living within 20 minutes walking of a community pharmacy and twice as many pharmacies in more deprived areas. Any change to the current commissioning arrangements would need to be carefully considered taking account of the impact this could have on access to pharmaceutical services.
July 2023