Written evidence submitted by the General Pharmaceutical Council (PHA0030)
About the General Pharmaceutical Council
As the independent regulator, we regulate pharmacists, pharmacy technicians and pharmacies in Great Britain. Our role is to make sure people receive safe and effective pharmacy care and have trust in pharmacy. Our work includes:
We welcome the opportunity to contribute to the Inquiry into the status of pharmacy in England and what the future of pharmacy could look like, including the current challenges and future innovations that could have the biggest impact to ensure that the potential of pharmacy is realised.
We have centred our comments around the key themes referred to in the Call for Evidence. We have limited our comments to those areas relating directly to our role and remit. This includes our knowledge and understanding of the issues affecting pharmacy from a regulatory perspective. In some instances, we have also shared information or intelligence about what others have told us or what we have learned about these issues through our regulatory role.
The Inquiry’s areas of focus
The Government has made it clear that pharmacy is a key part of the solution to many health and social challenges and that there is a significant opportunity for pharmacy to develop and take on a greater role in helping people to maintain and improve their health and wellbeing in the future.
We support this ambition and as the regulator, we have an important part to play – working collaboratively with patients, pharmacy professionals, employers and others to enable this to happen.
One of the major ways we are supporting this is through the development and publication of our standards for the initial education and training of pharmacists (2021), which will come into full effect in 2025/2026. The standards have been developed to produce adaptable pharmacists who will be confident and capable of operating in multi-professional teams across a variety of healthcare settings, to meet diverse and changing patient needs. This approach was supported by many stakeholders across pharmacy, with respondents to our standards consultation welcoming the stronger emphasis placed on clinical skills and the move to make prescribing a core part of the pharmacist role.
The phased implementation of these standards is transforming the education and training of pharmacists, so they are able to play a much greater role in providing clinical care to patients and the public from their first day on the register. By 2026, those registering as pharmacists will have trained to be more clinically and diagnostically focused, with further emphasis on person-centred care and use of professional judgement; and be able to prescribe at the point of registration as part of contributing to wider health delivery and how specifically this fits in to the greater whole of health care delivery.
Through our Advisory Group for Initial Education and Training, we are continuing to build on the significant collaborative work that followed the initial standards consultation in 2019, reflecting the importance of stakeholders, including employers, universities and statutory education bodies, working together to deliver this new and adaptable pharmacist workforce.
In parallel, our Advisory Group for Post-Registration Assurance of Practice is focussing on the development of education and training, revalidation and annotation and governance/contractual frameworks in light of new models of delivery, rapidly changing roles and multi-professional working across all pharmacy settings and increasing contribution to wider healthcare provision.
We believe that all pharmacy stakeholders must continue to work together collaboratively and with Government to ensure that education and training is fit for the future, which includes a focus on issues such as the Foundation training year, the availability of clinically-oriented placements and of Designated Prescribing Practitioners. We play a key role in enabling this. We note that these are also important themes within the new NHS Long Term Workforce Plan.
We agree that with the rapid pace of change within pharmacy and healthcare, the need to ensure both pharmacists and pharmacy technicians can use the full range of their skills is increasingly important. We know the positive and complementary differences in knowledge and skills of pharmacists and pharmacy technicians and other support staff in providing safe and effective care is an important part of discussions on the future of pharmacy.
As the regulator, we are ensuring through initial education and training and revalidation that pharmacy technicians are equipped for the roles they are and will be carrying out in the future and we have been developing our approach to the regulation of pharmacy technicians. This includes promoting parity in the professions and providing a regulatory leadership role in holding ourselves – and others – to account on achieving and maintaining this.
Current legislation is widely perceived as a barrier to the optimal contribution of pharmacy technicians, preventing effective use of pharmacists and the wider skill mix in pharmacy teams. Planned Government initiatives such as the public consultation on the rules surrounding supervision are therefore vital, to understand the sector’s views about how to make full use of pharmacy technician knowledge and skills and free up pharmacist time to deliver more clinical services, all of which are intrinsically linked with questions about the future of pharmacy and its capability and capacity to deliver on ambitions. We therefore hope that this work continues to progress in a timely way.
We understand that the Inquiry is interested in whether there are the right number of community pharmacies in the right places, and how to ensure this is the case across the country.
As the regulator, we hold unique data on the number of registered pharmacies across the Great Britain, including data on each of the three countries and we are able to identify previous and emerging trends.
We have set out some information below with relevance to the Inquiry’s focus on the numbers of community pharmacies. We also hold additional data on wider issues such as how registered pharmacies are performing against our regulatory standards and how this differs by pharmacy type or location. We are able to interrogate our data in different ways and we are happy to provide any further information or analysis that may be of assistance to the Inquiry going forward.
Numbers of pharmacies
The number of pharmacies on the register has continued to fall, extending the trend we have seen over the last few years. In 2022/23 the rate of pharmacies closing slowed compared to the previous two years with a fall of 0.3%, compared to 0.9% in 2021/22 and 1.4% in 2020/21. However, recently there has been a fall of 1.7% pharmacies in the past three months, largely driven by closures Lloyds Pharmacy outlets in Sainsbury’s supermarkets.
Over the last 12 months, the number of pharmacies in England has fallen by 266 (to 11,555), in Wales by 5 (to 721). The number of pharmacies on the register in Scotland has stayed consistent at 1,301. By country, the proportion of pharmacies is distributed 85% in England, 10% in Scotland and 5% in Wales.
The overall effect on the shape of the register of pharmacies, is a continued trend of the largest pharmacy groups reducing their premises numbers, and an increased share of independent pharmacy. Although Boots, Lloyds Pharmacy and Rowlands have continued to shrink their premise numbers, together with Well they remain the largest chains. In 2021/22 Avicenna and PCT Healthcare grew considerably (mainly through mergers and acquisitions) to join the league of chains with 100+ branches and numbers have remained stable since.
The number of independent pharmacies makes up an increasing share of the register, with 3,386 independent pharmacies (25.0% of the register). This is the now the biggest ownership group size on the register overtaking the number of pharmacies owned by multiples with over 1,000 branches.
Pharmacy closures (including temporary closures)
The causes behind the level of closures (including temporary closures) that we are seeing are both complex and multifactorial, including financial, commercial, labour market and contractual factors. These closures can be distressing for all involved, and potentially may raise concerns for patient safety, particularly if people cannot access the medicines and other pharmacy services many rely on. Closures can also impact on different groups or communities in different ways.
Although the number of pharmacies evolves at different points in time, our continued focus as the regulator is on patient safety and whether a pharmacy is operating safely and effectively. We require pharmacy owners and pharmacy professionals to meet our standards at all times. Any action to maintain service continuity needs to take into account that restricting services in certain circumstances may be appropriate if it is necessary in the interests of safety. We have a role in empowering and supporting all involved, including Responsible Pharmacists, Superintendent Pharmacists, pharmacy owners and all pharmacy team members, to fulfil their legal and professional responsibilities in relation to patient safety.
We have also received reports about locum rates and arrangements in this context, including providers with concerns about locums not following through on agreements as well as concerns from locums about the willingness of providers to pay market rates. While it is inappropriate for the regulator to play a part in setting or influencing locum rates, we do have a role in investigating any activity that could undermine public confidence in pharmacy or even potentially affect patient safety.
It's also important to highlight that pharmacy services are continuing to adapt and change, with patients accessing online services for medicines and treatment. We are continuing to evolve our regulatory approach to take account of these different models of service, and we are supporting people to keep safe when going online through advice and guidance.
We therefore support a co-ordinated and collaborative approach to workforce matters (including pharmacy closures) and we welcome the Inquiry’s focus on this important area. Understanding the extent of existing pressures directly from the pharmacy workforce is highly relevant to determining questions on future capacity and capability.
We understand that the Inquiry is exploring the extent to which digital systems used in pharmacy are interoperable with those in general practice and hospitals.
The Inquiry may be interested to note that we have seen issues relating to clinical records and interoperability being raised in Coroner reports over the past few years. To give some context, we proactively monitor the Courts and Tribunals Judiciary website for Coroner reports that may be of relevance to pharmacy and pharmacy regulation (including those where we may need to take regulatory action) and on occasion we receive requests for information or reports requiring a statutory response directly from the Coroner’s Office. Some of these reports have been directed at the GPhC for comment while others have been directed at other regulators, organisations, healthcare providers and the Government.
From the reports that we have reviewed, or received, we have seen some evidence of Coroners raising concerns about wider system integration issues, including in the specific context of online pharmacy.
For example, in a recent report (reference 2023-0046) the Coroner for Manchester North raised concerns about a lack of integrated system or records which could be accessed by multiple pharmacies and a lack of access to the GP Summary Care Records. In this case, the Coroner highlighted the following:
“Whilst each individual pharmacy had in-house safety checks to safeguard against over prescribing by their own pharmacy, there is no integrated system in place which would alert a prescriber to prescriptions that have been dispensed by other on-line pharmacies. As a result, it is currently possible for a patient to obtain excessive quantities of medication by simply placing multiple orders with different on-line pharmacists”.
In another report (reference 2021-0363), the Coroner for Leicester City and South Leicestershire highlighted that:
“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs”.
Ultimately, we expect pharmacy professionals to make and use records of the care provided and to work with others to make sure there is continuity of care for the person concerned and we provide guidance to help them to do that. Issues relating to integration can therefore impact on a professional’s ability to meet regulatory standards and can be an obstacle to safe and effective patient care.
Through our regulatory work, we have seen how medicines shortages issues can impact on patients, the public and the pharmacy team.
For patients and the public, this can mean increased or repeat journeys and visits to the pharmacy, causing additional stress. This can be particularly difficult for patients with specific needs or accessibility issues.
Medicines shortages can also cause considerable work for pharmacy teams trying to source medicines, leading to additional stress when pharmacy teams are already under pressure. Shortages can hinder a pharmacy’s ability to supply medicines in a timely manner, leading to concerns or complaints from patients and the public about continuity of care.
We have also seen examples of unprofessional behaviour associated with medicines shortages when everyone is under pressure or the reasons for shortages are not fully understood, which creates additional risks and issues.
We understand the Inquiry is interested in the extent to which community pharmacy has the resource and capacity to realise the ambitions in DHSC's Primary Care Recovery Plan. We note that the Primary Care Recovery Plan is designed to tackle the 8am rush and to make it easier and quicker for patients to get the help they need from primary care. The plan also sets out investment in pharmacy funding over two years to expand services offered by community pharmacy, including through Pharmacy First and other services such as pharmacy oral contraception and blood pressure services.
We note that DHSC has committed to consult the sector on the proposed expanded role. In our view, this is an essential step to truly understand whether pharmacy has the capacity and resource to deliver the plan and what else may be needed in the future. This, alongside all of the wider issues mentioned above, need to be considered holistically, to inform future thinking about pharmacy’s capacity to support and deliver on Government ambitions and commitments.
Diversity in healthcare, including in the pharmacy professions, supports improved access to services and a reduction in health inequalities. It also supports high standards, enabling talented people to enter and progress in their careers and ensuring a highly skilled and proficient workforce. And it encourages the future workforce, enabling potential pharmacists and pharmacy technicians to see themselves in the professions. There are also important correlations between the wellness and wellbeing of students, academics and the clinical workforce and the impact that this has on workforce effectiveness, patient safety and patient outcomes.
Through our stakeholder discussions and roundtable events with the sector, we have heard that some pharmacists and pharmacy technicians do not feel fully empowered to fulfil their potential due to different forms of discrimination, prejudice and racism. We have also heard that people’s wellbeing can be adversely affected by these issues, as well as wider factors such as workforce pressures, unhealthy working environments or lack of opportunities for professional development. We have also heard of the impact on pharmacy colleagues’ wellbeing of increasingly aggressive behaviour by some patients, which we have been told is a significant issue in terms of morale, burnout and retention.
Although the Inquiry is not focussed specifically on wellbeing or equality, diversity and inclusion, we believe these are important aspects of the bigger picture, and that pharmacy’s true potential and value will only be realised when these issues are tackled collaboratively and in parallel with the important themes highlighted above. Ultimately, making the health service a better place to work must be a shared endeavour so that we can continue to meet the needs of our patients and support our pharmacy people.
There is no doubt that pharmacists, pharmacy technicians and wider pharmacy teams are playing a critical role in supporting the NHS and social care services at this time, making a major difference to the diverse communities that they serve.
We fully support the Inquiry’s focus on the themes highlighted above and we believe that comprehensive engagement with the sector on these issues is essential to fully understand the reality of what can be delivered and what else may be needed to support pharmacy to reach its full potential in the future.
As a final point, and in parallel to the themes listed above, we would encourage Inquiry to consider these fundamental questions about the future of pharmacy through the lens of leadership and change leadership. Applying the right methodology and having the right leadership are essential to facilitate and achieve successful outcomes for the future of pharmacy. The UK Commission on Pharmacy Professional Leadership highlighted the importance and value of pharmacy professional leadership and the connection that professional leadership has with independent regulation.
July 2023