Written evidence submitted by Boots UK (PHA0035)

About Boots UK

As the UK’s largest pharmacy chains, and one of the most trusted brands in the country, Boots plays a vital role as a community pharmacy, caring for people, customers and patients everywhere. Our pharmacies, from community stores to flagship destinations, are committed to supporting our patients and customers for life through a wide range of services. We are at the centre of community pharmacy and are a key partner to the NHS. Together, we agree new and innovative ways pharmacists can provide healthcare on the high street, designing services that can support our patients at every stage of their lives. We offer over 100 healthcare services in store and online.

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

1.1   Between 2017/18 and 2022/23, patient ‘touchpoints’[1] between community pharmacists and patients through nationally commissioned clinical services alone rose from 5.7m to over 10m. This trend will continue as pharmacies are commissioned to deliver further NHS services and an increasingly clinical future is realised.

1.2   We believe community pharmacy could have a bigger and more critical role within the Primary Care system, establishing themselves as community health centres providing a range of pharmacy, screening and clinical services. Through this extended role, community pharmacies could be a health hub with robust links into other healthcare professionals where patients will experience seamless and integrated care. They will help address the NHS’ current challenges, including primary care access, and improve health and wellbeing outcomes.

1.3   The vast majority of the population can access a community pharmacy within a 20-minute walk and, crucially, access is greater in areas of highest deprivation. This accessibility and convenience of locations will mean that the sector can increasingly be the first port of call for treatment for a wide range of common acute conditions. Thanks to Patient Group Directions (PGD) and Independent Prescribing (IP) capabilities, community pharmacists are able to provide the right treatment for minor illnesses and experiences. This has been successfully implemented in Wales and Scotland.

1.4   In addition, community pharmacy teams could provide additional services, including supporting patients with the management and maintenance of long-term conditions using a range of capabilities such as biometrics, titration and optimisation of medicines though IP and tools to support medicines adherence.

1.5   Furthermore, community pharmacy teams will continue to support the prevention agenda, and could play a greater role in this area, offering a wider range of vaccinations and screening services for long term conditions and provide expert advice to support positive lifestyle and behaviour change.

1.6   This ambitious vision for the future of community pharmacy will ensure optimal value for the NHS and patients but will only be realised if it is accompanied by appropriate funding, fit for purpose contractual and regulatory frameworks and an adequate professional workforce plan.

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

2.2   The current funding shortfall and workforce shortages facing the community pharmacy sector has caused increased pressure for the sector and made the working environment for community pharmacy colleagues extremely challenging, leading to more employees leaving the sector.

2.3   91% of pharmacies are experiencing staff shortages[2]. Workforce issues have led to locum pharmacist costs rising by 80% in 2021 and staffing costs overall have grown by close to 70% since 2015/16.

2.4   This situation is largely fuelled by the Primary Care Network’s (PCN) recruitment of pharmacists. Between March 2019 and March 2022, c. 4,700 pharmacists have left community and hospital pharmacy settings to work in General Practices. We have recently welcomed the recognition of these pressures in the recent NHS Long-Term Workforce Plan.

2.5   Furthermore, following the COVID-19 pandemic, there has been a shift in the importance of work/life balance for healthcare professionals. More of them are seeking earlier retirement, wishing to reduce their working hours or days and desiring to avoid working unsocial hours and at weekends.

2.6   In order to increase the attractiveness of community pharmacies, we need to create an optimal environment for clinical practice and an appealing proposition for pharmacy professionals to work in. Pharmacy professionals need the time and space to deliver high quality care. This can be delivered with investment and appropriate funding.

2.7   One way to make community pharmacies more attractive to pharmacists is to increase the clinical roles that can be undertaken within that setting and taking other steps such as facilitating ‘portfolio’ careers for community pharmacists to work in other primary care settings. Community pharmacies should be allowed to access ARRS funding and be commissioned to deliver ‘packages of care’ such as Structured Medication Reviews on behalf of PCNs or GPs. 

2.8   We are very pleased with the current bold transition programme to bring IP to the community pharmacy sector in England. This will be a key enabler to enhance the value and attractiveness of the community pharmacy sector. However, there is a significant challenge to upskill the legacy community pharmacist workforce to become IP[3] with data showing that only 5%[4] of community pharmacists have independent prescribing qualifications. We are notably currently seeing a lack of access to Designated Prescribing Practitioners (DPPs) which will limit the qualification of IPs.

2.9   Enhancing the role of pharmacy technicians in the community would also help to maximise the skill mix within pharmacy teams. We welcome the upcoming consultation on allowing pharmacy technicians to administer and supply medicines under Patient Group Directions (PGDs). This may also reduce the loss of community pharmacy technicians to other primary care and secondary care roles.

2.10                     We welcome the NHS Long-Term Workforce Plan’s recommendation that the sector should consider apprenticeships for pharmacy technicians and a pharmacist degree apprenticeship. While the plan lacks details at this stage, we believe that providing alternative routes for young people into the profession is critical. This would also provide a unique opportunity to have a more flexible apprenticeship policy framework to help maximise employer investment in skills training, and to allow firms to utilise more of their levy funds.

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

3.1   The current level of interoperability of community pharmacy systems with those in general practice and hospitals is not fit for purpose and leads to inefficiencies within the end-to-end system and unnecessary levels of administrative burden.

3.2   We welcome the NHS England digital roadmap, as described in the delivery plan for recovering access to primary care. The plan to implement GP Connect and the Booking and Referral Standard (BaRS) into community pharmacy systems offers significant improvement to enable efficient clinical communication for community pharmacy with the wider health system.

3.3   Adoption of the BaRS will allow pharmacy teams to digitally receive referrals into community pharmacy systems using a standardised infrastructure and point of access compared to present day whereby referrals can be received via NHSmail, wed-based systems or directly into the PMR.

3.4   Development within community pharmacy systems to implement GP connect will give pharmacists access to relevant clinical information from the GP record to provide a wide range of clinical services to patient though PGDs and IPs in future. This key integration will also seamlessly update the GP patient record with outcomes from community pharmacy services using nationally agreed data standards, as defined by the Professional Record Standards Body (PRSB), which are critical to any future digital developments to ensure seamless interoperability across the entire health system.

3.5   We are pleased with the clear vision presented by DHSC for the NHS App to become the digital front door to NHS care. However, we would welcome further engagement with the community pharmacy sector to explore any potential integrations with existing community pharmacy systems to optimise the value that can be achieved for patients. This would include the integration into internal appointment booking systems to allow patients to book appointments via the NHS App using NHS National Booking System and enabling patients to order their prescription via the NHS App utilising existing online services and pathways offered from contractors.

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

4.1   There is significant opportunity for digital tools such as mobile app technology to be used more widely by patients to improve their health outcomes.

4.2   For instance, mobile apps can promote medicines adherence and encourage patients to take their medicines correctly. This has the capacity to improve patient outcomes and reduce hospital admissions.

4.3   Digital tools can also be used to amplify face to face “nudge’ behavioural change interventions delivered by pharmacy teams to support patients’ positive lifestyle choices. This can take place through reminders, logging actions and providing feedback to clinicians.

4.4   The emerging use of Artificial Intelligence (AI) can provide extensive benefit to community pharmacy. We believe that it can increase pharmacy teams’ capacity and free their time by enabling clinical checking of the appropriateness of patients’ prescription items. Any use of AI must be appropriately regulated by the MHRA to ensure optimal levels of patient safety and instil trust in pharmacy professionals that any solutions are safe to use.

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

5.5   The current funding arrangements in England through the Community Pharmacy Contractual Framework (CPCF) are too low. Using official government figures, the Company Chemists Association (CCA) recently highlighted that the funding shortfall in the sector is more than £750m per year, equating to £67,000 per pharmacy. This has meant that there is currently no free cash flow for contractors to invest in innovation, with all current revenue focussed on maintaining day to day operations and providing basic pharmaceutical care to patients. The recent funding announcement from the Primary Care Recovery Plan is welcome but represents new money for new work and does not address the systemic lack of funding.

5.6   To enable innovation within the sector, meet the future vision of the community pharmacy sector and become an integral part of primary care, contractors need capital investment in facilities, alongside investment in people and training in a way that makes community pharmacies sustainable.

5.7   Furthermore, a firm commitment and a plan for sustainable funding for community pharmacy is critical to give the sector confidence and clarity on the future to make any long-term investments.

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

6.1   While medicine shortages are caused by a range of issues, community pharmacists have been at the forefront of the crisis and have spent significant amount of their time finding supplies. On average, pharmacy staff spend 6.3 hours per week dealing with medicine shortages[5].

6.2   In future, medicines shortages can be managed through changes to regulation to allow pharmacists to make appropriate substitutions without the requirement to contact the prescriber to issue a replacement prescription and reimburse based on medicine supplied, not prescribed. The current process to contact the prescriber to get a replacement prescription issued involves unnecessary levels of burden to a process where the clinical expertise of the pharmacist can be used effectively to issue a replacement medicine without contacting the prescriber.

6.3   Progress has been made to introduce Serious Shortage Protocols (SSPs) for specific medicine shortages, although these are often introduced once an issue has already manifested and also involve overburdensome levels of administration and process.

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

7.1   We welcome the range of items listed in the Primary Care Recovery Plan,. However, the full benefits of the plan cannot be realised without the existing capacity issues being solved – which are as a result of the core funding gap. Further investment in the sector is critically needed over and above the £645m to address these issues and to provide the capacity needed to fully realise the proposed plan.

7.2   Investment in the sector must also address engagement and training of the locum workforce to embrace aspects of new CPCF to ensure a consistent provision of clinical service availability from community pharmacies. This is of further importance as a result of the current workforce pressures facing the sector as result of community pharmacists moving into Primary Care Network roles through the NHS ARRS putting an increase demand the utilisation of locum pharmacists.

7.3   To free up pharmacists and registered technicians to deliver the items in the plan, investment also needs to consider recruitment and training of pharmacy support staff to backfill and free up pharmacists and technicians to complete work that doesn’t require professional qualifications.

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

8.1   The funding framework defined in the current Community Pharmacy Contractual Framework (CPCF) means that community pharmacies in England must provide both items and services to enable a sustainable business model. Due to the current funding crisis and real term fall in funding, this has led to the current sector crisis and questioning of pharmacy numbers.

8.2   When we review the UK landscape more widely, it is essential to note that the other UK countries: Wales, Scotland and Northern Ireland, did not adopt the contract exemptions that were introduced in England and all have maintained strong provision of pharmaceutical care with consistent numbers.

8.3   We would also recommend that the mechanism of the Pharmaceutical Needs Assessments (PNAs), which aims to assess the current and future pharmaceutical needs of the local population, to be reviewed so that the templates and process are standardised and stay consistent across the country. This will help have community pharmacies in the right places and where they are the most needed.

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

9.1   The commissioning arrangements for both national and local frameworks within community pharmacy are not fit for purpose. The current 5-year national CPCF was based on sizeable and incorrect assumptions, and failure to adjust the national contract to account for these assumptions has led to the current funding shortfall facing the sector.

9.2   Automation does not always enable efficiency. As detailed in the DHSC hub and spoke impact assessment[6], the level of benefit from large scale automation is minimal. Furthermore, there has not been a plentiful supply of pharmacy professionals. The impact of the pandemic on healthcare professionals’ perception of work/life balance and the NHSE creation of 6-7 new PCN pharmacist roles has significantly impacted the community pharmacy workforce. Finally, inflation has not remained at historic lows causing increased costs in the context of a flat funding package.

9.3   Regarding local commissioning, current regional variation and inconsistency in delivery and governance processes at a local level have created unnecessary burdens for organisations with a national reach and ultimately diverts workforce away from delivering patient-facing care. In future, it is essential that service protocols and clinical governance arrangements for local services are defined nationally and implemented locally without the burden of additional local variation.

9.4   A clear example of variation in commissioning from community pharmacy can be seen in the provision of Emergency Hormonal Contraception (EHC) services. Geographical variations in which local pharmacies can provide EHC services, who is eligible and what treatment options are offered can cause confusion for women who urgently require the service. There are no clear reasons why this commonly commissioned service should vary so much.

9.5   To solve this, we recommend that local commissioning arrangements are reformed to enable efficient and consistent commissioning models, for example through a wider use of National Enhanced Services as used for Covid-19 vaccinations. In addition, the NHS Short Form Standard NHS Contract must be mandated if local services are not delivered through a National Enhanced Service.