Written evidence submitted by Professor Ellen Schafheutle (Professor of Pharmacy Policy and Practice at The University of Manchester); Dr Imelda McDermott (Research Fellow at The University of Manchester); Dr Sarah Willis (Senior Lecturer in Healthcare Management at The University of Manchester); Dr Sally Jacobs (Lecturer in Pharmacy at The University of Manchester); Dr Jayne Astbury (Research Associate at The University of Manchester); Dr Ali Hindi (Lecturer in Pharmacy Practice at The University of Manchester) (PHA0039)

In summary

• Community pharmacy has the potential to be a great asset to public health, particularly in deprived communities.
• Realising this means better transparency and quality assurance systems, alongside better integration of IT systems, and data sharing and editing privileges for pharmacists.
• However, the latter must be balanced with trust and acceptability from patients, GPs and their teams, with assurances in place around how data can be accessed and used.
• Fundamental to the goals of the Primary Care Recovery Plan, and indeed the recently announced NHS workforce plan, as well as other strategies for the integration of pharmacy into primary care, is staff training, recruitment, and retention.
• Pharmacy technicians must be used effectively, with pharmacists encouraged to delegate work to them so the latter can focus on clinical duties.
• Pharmacists and pharmacy technicians should have better access to in-work training, support and development, from pre-registration foundation, through newly qualified and advanced practice.
• This requires a cultural shift within the community pharmacy sector, alongside steps to address low job satisfaction, high workloads, limited career progression, and relatively low pay.
• With regard to integration of community pharmacy into Primary Care Networks, there is still work to be done, but our research so far suggests that adding pharmacists to GP surgeries results in improved prescribing outcomes.
• Funding is a major issue for the community pharmacy sector.
• Per-item funding for dispensing has fallen over time, and there is insufficient funding available for expansion of professional pharmacy services.
• Coupled with ‘top-slicing’ of budgets, this has led some pharmacies to focus on quick, high-volume ‘easy wins’ – rather than higher quality, more complex services.
• Commissioning of community pharmacy services is fragmented, causing issues around business planning, and therefore staff recruitment, training, and retention.
• Under new General Pharmaceutical Council standards for initial education and training, from 2026 newly qualified pharmacists will also be prescribers.
• In community pharmacy, this fits with the ‘Pharmacy First’ approach of the Primary Care Recovery Plan (a service for common conditions).  It is crucial that pharmacists do have a service to apply their new prescribing skills to, as we know that without this, prescribing skills and confidence are soon lost.
• It is also important that existing pharmacists are supported to become independent prescribers, so that they can equally contribute to the NHS primary care recovery plan.
• Overall, the community pharmacy sector needs long-term commitments around funding, to facilitate better business planning. This includes early and constructive engagement between NHS England and community pharmacy organisations including Community Pharmacy England.
• This needs to be coupled with more incentives, and a culture shift, for training, support, and development opportunities.

In detail

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

For community pharmacy, the future cannot (and should not) be ‘just’ about medicines supply. However, income from supply – the dispensing of prescriptions – remains the majority of income for community pharmacies.

Since the first big change to the Community Pharmacy Contractual Framework (CPCF) in 2005, community pharmacies have been offering a range of medicines, clinical and public health services. Indeed, community pharmacies, located in areas of high deprivation where general practices can be lacking[1], have much potential in public health and as an ‘asset’ in local communities.[2]

As part of wider drives towards integrated care pathways, there is a need to develop effective and transparent quality assurance systems for community pharmacy. These need to ensure quality of services within, and by, community pharmacies, as well as facilitate better integration with wider primary care. IT systems and inter-operability with other primary care systems will be a fundamental part of ensuring better integration, creating a better patient experience.

Realising this future will require a larger, more technically and clinically skilled workforce. To ensure adequate numbers of pharmacists and pharmacy technicians, training must be enhanced in all sectors. Experience with cross-sector training to achieve this has been positive[3],[4]. Currently, as private sector organisations providing public/NHS-funded services, some community pharmacies opt-out of supporting work-based training of pharmacy professionals prior to their registration (and beyond). With pharmacists in particular registering as ‘prescriber ready’ from 2026, there is a real need for ensuring training and support in all sectors, to create and advance the future workforce.

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

The pharmacy workforce – consisting of pharmacists and pharmacy technicians, both regulated by the General Pharmaceutical Council (GPhC) – is undergoing significant changes to enable them to fulfil the needs of the NHS, and support a primary care system under pressure. From 2026, pharmacy students currently in training will register as pharmacists, and simultaneously qualify as prescribers.

This creates opportunities for pharmacists to deliver the ambitions set out in the NHS England recovery plan. However, this must be underpinned by proper workforce planning and governance which looks across the whole health system – if pharmacists are to take on enhanced roles, then other workers, particularly pharmacy technicians, must be suitably trained and capable of taking on (and/or safely substituting for) some of the work which was done by pharmacists.

There are new (2017) GPhC standards for the initial education and training of pharmacy technicians, so recent registrants qualify with more advanced skills. These pharmacy technicians need to be used effectively, and pharmacists must be supported to delegate work to them – particularly managing medicine supply – so that pharmacists are able to work clinically and autonomously at the top of their license. So far, however, progress has been slow, with many pharmacists showing reluctance to ‘let go’ of more time-consuming checking and dispensing issues. There are lessons to be learned in the community pharmacy sector from hospital pharmacy, where delegation of these duties has been managed more effectively.[5],[6]

However, the increase in responsibility for pharmacy technicians must be accompanied by proper governance, as well as salary uplifts and other steps to reflect this work. This is currently not the case.

In terms of retention, the contributors to this article are currently undertaking research into reasons for pharmacy technicians to leave the workforce. So far, this has found issues around job satisfaction in community pharmacy, alongside high workloads, low salaries, and limited opportunities for career progression. We would be happy to share this research with the Committee when published.

Of course, training to support advances in practice and skills requires capacity within the system for effective educational supervision. We have undertaken research, and believe we have a model of what works[7],[8],[9];

• Having a standard model of supervision, with access to support and supervision in either the workplace or externally via educational supervision.
• A commitment from any private-sector providers taking public funding to ensure training pathways are available.
• There is currently a poor culture of learning in the pharmacy sector, alongside a lack of commitment to training from the private sector providers.
• In-work training, including the ‘buying-out’ of time for learning and training.

However, our evidence also shows that training alone does not change practice. There is a pressing need for a culture of learning and support in the workplace, at all stages of a pharmacy professional’s career. It must be the case across all sectors and settings – whether directly publicly funded or private sector providers of public services (including community pharmacies) – that there is an active involvement and commitment to supporting the future workforce. For community pharmacies, this includes ensuring that, prior to registration, the right balance is struck between time spent as a ‘worker’, and time spent as a supported ‘learner’.[10],[11],[12],[13],[14]

This culture change must precede policy visions around commissioning, funding, and organisation of the sector – it is currently the reverse, with policy coming before the engagement with the pharmacy sector. Collaboration is needed with bodies such as Community Pharmacy England to embed culture change, so the sector is best prepared to meet the responsibilities being asked of it.

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

We know that there are a range of problems with interoperability between general practice and community pharmacy, despite it being key for integration across healthcare sectors and systems. There are different IT providers across general practice, and yet more in community pharmacy. These create barriers to local collaboration, creating a postcode-lottery for good, conducive communication and collaboration.

The recent introduction of Primary Care Network (PCN) level pharmacy leads may help, as previously, pharmacy professionals were not often ‘round the table’ when system level healthcare decisions were made.

Currently, community pharmacists and pharmacy technicians only have access to the summary care record, which provides only very basic details on past and current medications and allergies. While helpful for checking eligibility for services such as free flu jabs, or preventing prescribing errors and ensuring patient safety at a relatively basic level, more detail is needed for pharmacists to fulfil their full clinical potential.

Community pharmacists are supportive of having better access to patient medical records to support their increasingly clinical roles.[15] It would be ideal for them to have some read/write access – already in place in some places for services such as the Community Pharmacists Consultation Service (CPCS) – so that relevant clinical information can be shared contemporaneously, without adding further layers (and inefficiencies).

However, GPs and patients are not as supportive, with some concerns over the commercial nature of community pharmacies, and who would have access to a patient’s personal and medical information.[16] There is trust in community pharmacists themselves, but some uncertainty around other support staff, some of whom have only limited healthcare training. Assurances need to be in place for appropriate and authorised access.[17]

In Greater Manchester, The University of Manchester is leading on the creation of an integrated care record, joining up health and care data from primary, secondary, and community sources into a single record for each patient. Deployment of a similar system across England would not only give community pharmacists access to the greater level of detail needed to fulfil new responsibilities, but would also go some way to easing the wider issue of poorly joined-up data records affecting many facets of the health and care sector.

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

Skills mix is an important innovation to consider. Accuracy-checking pharmacy technicians (ACPTs) could take more responsibility for supply and dispensary management, to free-up time for pharmacists. While not an ‘innovation’ per se, this is still not routine practice, and more could be done to encourage this.

Pharmacists still do much of the checking, despite ACPTs being trained as accuracy checkers. ACPTs should be supported to have leadership skills and confidence, and to take the initiative and responsibility to reorganise their workplace. This is something they are able to do if properly supported[18], but it requires a cultural change (see response to Q2 on training and culture).

Our skills mix study[19] found that the employment of clinical pharmacists in general practice has clear benefits in terms of prescribing quality and volume. A higher full-time equivalent (FTE) of clinical pharmacist is associated with higher prescribing quality and lower prescribing volume. However, there need to be adjustments to current pharmacy training programmes – working in hospital settings is quite different to working in primary care, and practitioners can feel isolated when working alone in the latter.

Analysis of workforce composition and outcomes confirm the positive effects of health professionals – which includes pharmacists as the largest subgroup – on prescribing practices and patient safety.[20] Longitudinal analysis also shows that having pharmacists integrated into GP surgeries improves medicine prescribing outcomes.[21] However, broader integration of pharmacists in PCNs is still lacking.

Research is currently underway assessing the contributions of staff funded under the Additional Roles Reimbursement Scheme study. This work includes a stream on pharmacists and pharmacy technicians working in PCNs.

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

In a sentence, they are not.

Dispensing of medicines remains, of course, the main ‘essential service’ in community pharmacy, and hence, the main source of income. It is a predictable income stream, and so a core part of business planning. Nevertheless, while the number of items prescribed has increased steadily year-on-year, the per-item income has reduced over time.

Funding mechanisms, through the community pharmacy contractual framework (CPCF) (first introduced in 2005, and revised in 2019), have introduced different types of funded services. From 2019, these mechanisms have attempted to incentivise quality as well as quantity. However, it has – until very recently – also been accompanied by continuous cuts to community pharmacy funding.

Insufficient funding for expansion of services removes any incentive for pharmacies to do this well. Staffing levels are being cut at a time when they should be increasing, to support pharmacists to take on more clinical roles. Workloads have increased[22], pharmacists report overloading and stress, and patient safety is threatened.[23],[24]

Since the introduction of the CPCF, one key problem with the funding model has been that it depended on top-slicing existing budgets, and then requiring pharmacies to earn it back on a fee-for-service basis. This has led to the unintended consequence of pharmacies looking for ‘easy wins’ in terms of quantity and volume, rather than targeting more complex, higher quality work. We observed this with the medicines use reviews (MURs) introduced under the 2005 CPCF.[25]

MURs were one of the first services introduced under the CPCF, as a first funded step to facilitate the introduction of pharmacists’ clinical services in community pharmacy. MURs introduced pharmacist consultations with patients on multiple medicines, focussing on patient understanding and medicine adherence. However, the focus on quantity and regaining (lost) funding has led pharmacy owners and companies to exert intense pressure on pharmacists to meet targets for the maximum number of MURs that can be claimed for (400 per year per pharmacy). Hence, the inverse relationship between population need and volume of service delivery, and indeed the dominance of chain pharmacies in terms of those delivering highest volumes.

Following numerous changes to MURs, they were eventually phased out under the 2019 CPCF. While patients who had had a MUR were commonly positive about their experience, the services was not well integrated within primary care, limiting its value.

Commissioning of community pharmacy services has been fragmented, making business planning difficult, and somewhat unpredictable.[26] This has also led to uncertainty and community pharmacy owners’ reluctance to invest in staff and staff training.[27]

Under the 2019 CPCF, a scheme of quality incentives called the Pharmacy Quality Scheme (PQS) was introduced, linking payments to set criteria including audits and specific staff training. Our research team, in collaboration with ICF, are currently evaluating the PQS. This work is commissioned by NHS England, and the report is due Autumn 2023 – we would be very happy to share it with the Committee when it is released.

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

We have not worked directly on this, and are therefore unable to comment, but as part of this inquiry, the Committee may want to explore the impacts of sourcing of needed medicines and specifically serious shortage protocols on the administrative burden of an already short-staffed sector.

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

The services which were announced and planned under this recovery plan are a ‘Pharmacy First’ common conditions service, which will enable pharmacists to treat a small number (7) of clearly identified common infections, with advice and (potentially) the supply of antimicrobials normally only available on prescription. This would be facilitated under strict clinical protocols, designed under clear antimicrobial resistance (AMR) protocols and with so-called ‘patient group directions’ (PDGs), which enable the supply of prescription-only medicines (POM). There are also plans for NHS pharmacy contraception and hypertension case-finding services to be available in community pharmacies.

Community pharmacy has the potential to meeting these ambitions, provided there is a predictable and longer-term commitment to funding. This would ensure that community pharmacy business planning can include additional staff, and/or more highly qualified staff, to deliver such services.

Pharmacists are increasingly trained as clinical professionals, with the skills and confidence to conduct holistic patient consultations and recommend treatment. This is currently being introduced, under new GPhC standards for the initial education and training, and from 2026, newly qualified pharmacists will also be prescribers. The most likely area for them to practise their prescribing skills will be common conditions management, and the supply of POMs. As such, the Pharmacy First service paves the way for this transition.

However, there are some concerns over resource and capacity to support the training (from mid-2025) of pharmacists as independent prescribers. This requires clinical supervision, yet most pharmacies are staffed by just one pharmacist, and most are not themselves independent prescribers – and hence not able to offer the required supervision (as a so-called dedicated prescribing practitioner). This will be even more important under the planned increase in training places for pharmacists by nearly 50% to around 5,000 places by 2031/32, as announced in the NHS workforce plan..

It is crucial that pharmacists do have a service to apply their new prescribing skills to, as we know that without this, prescribing skills and confidence are soon lost.[28] It is also important that existing pharmacists are supported to become independent prescribers, so that they can equally contribute to the NHS primary care recovery plan.

Prescribing pilots are currently underway to test implementation in community pharmacy. Skills advancement and related confidence-building was supported under the Pharmacy Integration Fund (PhIF) training pathways, particularly for ACPTs, and also including community pharmacists. However, funded training did not – at that time – include a prescribing qualification for them. Our research found that this PhIF training positively impacted pharmacists’ practice, identity and patient outcomes, including in community pharmacy.23, 25, [29]

However, we also found that services commonly did not exist in community pharmacy, which would have facilitated application and embedding of these higher level, clinical skills. As such, there is a risk they are lost if no suitable services are commissioned – at the point when many new pharmacists will qualify as prescribers from 2026.

Community pharmacy employers were often not supportive of their pharmacists accessing PhIF training, as – without services where pharmacists could apply their skills – they could not see the longer-term benefits for the pharmacy business.  They were also concerned that, with these additional skills, pharmacists would leave them and move into newly created clinical pharmacist roles in primary care .6, [30]

Staffing is tight and workload pressures are high in community pharmacy.18 This links closely to the fact that the expansion of services is not supported by sufficient funding (see answer to Q5). Therefore, while more services are introduced, staffing levels are being cut as a direct result of insufficient funds.

There is no real ‘culture’ of supporting learning in community pharmacy[31], [32] and very limited resource for supervision to facilitate the learning and advancement of clinical skills. Some early career support is being implemented, to make access to such training more equitable across sectors, and we are in the process of evaluating this, commissioned by Health Education England (HEE). This support – a combination of formal learning and in-practice supervision – has traditionally been part of early career pharmacists’ practice in hospital (which does have support and supervision structures, and indeed a learning culture) but not in community pharmacy.8;10;12 Our work has indeed informed the HEE funded programme which we are currently evaluating.[33] We would be happy to share this work with the Committee, once published.

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?

We are not able to comment on this topic, but the Committee may wish to explore how pharmacy is affected by the ‘inverse care law’; whether pharmacy closures are happening disproportionately more in deprived areas, and whether PQS funding is going disproportionately to more affluent areas. Until now, community pharmacies have been more likely to be located in deprived areas than GP practices.

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

Our research22 has shown that commissioning for services can be fragmented, and that planning and commissioning can be both short notice, and of short duration (of ‘guaranteed income’). This makes planning for community pharmacy owners (large and small) difficult, as they tend to plan their business about 12 months in advance. Early engagement with community pharmacy stakeholders (including Community Pharmacy England and others representing pharmacy contractors) is crucial for alignment of policy intention and implementation.

Local and fragmented commissioning may also not work for patients, as it is not patient-centred healthcare. Minor ailments schemes, for example, were commissioned locally, and so not all areas provided the service (yet patients did not know which). Furthermore, each locality had agreed different service specifications, meaning what was available in one area under a minor ailment scheme was not in the one next door.

The short-term nature of different funding and income steams for services means that long-term planning can be difficult.  Yet, that is needed for longer term investment in both workforce and skill mix, and underpinning training to support the workforce in new or advanced roles.

10. A final comment

It is notable that, in any of the questions posed in this inquiry, there is no sense of acceptability of services to patients; all of the questions focus on feasibility. Yet it is crucial that the patient experience – their pathway to health and care, and cost-effective, positive outcomes – are placed at the centre of these considerations.