Written evidence submitted by The Pharmacists’ Defence Association (PHA0046)

Health and Social Care Committee Inquiry into Pharmacy

The Pharmacists’ Defence Association (PDA) welcomes the opportunity to provide written evidence to the Health and Social Care Committee’s inquiry into pharmacy.

The PDA is the largest representative organisation and only independent trade union exclusively for pharmacists.  With over 36,000 members across the UK, the PDA is the voice of individual pharmacists working on the NHS frontline and across all healthcare settings, including GP practice, community, hospitals and prisons.

We have responded to the questions set out in the inquiry terms of reference and our key points are also summarised below.

• The PDA believes that pharmacists in all areas of practice should be enabled to focus on pharmaceutical care to better support the safe and effective use of medicines and ensure that the investment of public money in medicines is well spent.
• There needs to be an overall long-term strategy outlining the vision of how changes to pharmacists’ initial education and training can be built upon to deliver a more holistic pharmacy service, supported by the NHS Long Term Workforce Plan.
• Currently in community pharmacy there are several challenges around recruitment and retention. Consistently, pharmacists tell us in significant numbers about what influences their decisions about where they work and how conditions impact on their health and well-being. These include understaffing, sub-standard working environments, lack of protected training time and experiences of violence and abuse.
• The key to unlocking the full potential of community pharmacists is by ensuring that pharmacists can have full read/write access to patient records.
• There is a huge opportunity to reconfigure funding arrangements to enhance the proportion that is distributed to the provision of clinical pharmacy/pharmaceutical care in relation to the proportion devoted to the mere supply of medicines. It is essential that funding increases are ringfenced so that they are used for the purpose of healthcare delivery.
• Pharmacists can spend a significant amount of time dealing with medicines availability. The causes of medicines stock issues are multifaceted; pharmacists are seeking transparency and acknowledgement of supply challenges, along with the adoption of practical solutions at an early stage when shortages occur, so that that they can guide patients and other healthcare professionals on the best course of action.
• The whole issue around pharmaceutical needs assessments (PNAs), needs a radical overhaul to ensure that the NHS gets the absolute best value for money. To date there has never been an evaluation of the effectiveness (or otherwise) of PNAs, which are supposed to ensure adequate provision of pharmacies in local areas.
• The right commissioning framework, supported by the suitable skill mix and services which focus on clinical pharmacy/pharmaceutical care of patients could deliver a similar scale of patient acceptance in receiving a wider range of services from a community pharmacy setting, as has been successfully demonstrated by flu and covid-19 vaccinations services.

Response to the inquiry questions

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

1.1   Pharmacists, wherever they work, are experts in the safe and effective use of medicines. Pharmacy, including community pharmacy, needs to be reorientated to a focus on integrated pharmaceutical care, to improve patient outcomes, and provide the most appropriate care in the right place at the right time. This will deliver good value to the public expenditure on medicines, which is currently upwards of £35bn, and reduce the amount of medicines that are wasted.

1.2   Reducing medicines waste can deliver financial and environmental benefit as well as improving patient care.

1.3   The PDA’s Wider Than Medicines[1] strategy integrates the work of primary care pharmacists, GP practice-based pharmacists, group practice pharmacists, hospital pharmacists and community pharmacists. By taking charge of the medicines and pharmaceutical care agenda, Wider Than Medicines highlights how pharmacists are integral to securing the long-term health of the public as well as to meet important NHS aims.

1.4   Despite the recent focus on the introduction of independent prescribing by pharmacists and changes to the initial education and training to facilitate this, the strategy as to how pharmacists specifically could be better integrated into patient pathways and build on their current role in a strategic and long-term plan is largely missing. We have recently seen the introduction of new services as part of the NHS England (NHSE) delivering access to primary care recovery plan[2], and the plans around the NHS workforce[3], but there needs to be an overall long-term strategy for how this can be built upon to deliver a more holistic pharmacy service.

1.5   According to ONS data, the total pharmaceutical expenditure[4] in the UK stood at £39.6 billion in 2021, 14.1% of current health expenditure, representing both the final use of medicines and those used in wider courses of treatment.

• 40.8% relating to spending on community-prescribed medicines

• 19.7% on over-the-counter medicines
• 20.9% relating to immunisation programmes
• 18.6% relating to medicines administered as part of courses of treatment

1.6   Whilst this figure may have been slightly affected by the Covid-19 pandemic, with

the provision of large scale-immunisation programmes for example, there is an ongoing and significant investment of public money in pharmaceuticals which need to be deployed appropriately.

1.7   Alongside the increasing public spending, which can also be attributed to people living longer but with more chronic health conditions, research has shown that those same medicines are, in some cases causing harm to patients due to a lack of pharmaceutical care.

• Up to 7% hospital admissions are of patients harmed by the medicines that they are taking (NICE)
• Non-Compliance around the safe and effective use of medicines linked to;
• 48% of asthma deaths[5]
• 80% increase in risk of diabetes (Elliot R)[6]
• £359million Adverse Drug Reactions (National Patient Safety Agency)

1.8   In 2021, the Department of Health and Social Care published their report[7]

Good for you, good for us, good for everybody, a plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions.

1.9   The report highlighted that overprescribing has two main causes:

• systemic: key factors are single-condition clinical guidelines, a lack of alternatives to prescribing a medicine, a need for on-going review and deprescribing to be built into the process of prescribing, inability to access comprehensive patient records, the lack of digital interoperability, and pressure of time.
• cultural: a healthcare culture that favours medicines over alternatives and in which some patients struggle to be heard.

1.10           Solutions offered by the Department of Health and Social Care included that the NHS long-term plan supported the expansion of pharmacy professionals in Primary Care Networks in England, funding the deployment and specialist training of thousands of clinical pharmacists and pharmacy technicians.

“This will allow clinical pharmacists to provide much more effective support to GPs and other prescribers across the practices in the PCN. In particular, they will be able to provide comprehensive reviews of the medication regimes for the most vulnerable patients through Structured Medication Reviews”.

1.11           The aims were that Structured Medication Reviews could “reduce unnecessary hospital admissions and events such as falls and help the £20.9 billion NHS medicines budget go further by reducing the proportion of medicines that are not taken by patients as prescribed”.

1.12           The PDA believes that pharmacists in all areas of practice should be enabled to focus on pharmaceutical care to better support the safe and effective use of medicines and ensure that the investment of public money in medicines is well spent.

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

2.1   The issues around workforce are not straightforward and there are a substantial number of complex interrelated issues that need to be considered in a holistic way. There are currently over 60,000 pharmacists on the General Pharmaceutical Council (GPhC) register, and this number continues to grow year on year (having increased by over 5,000 in just the past 3 years) [8]. There is no evidence of a shortage of pharmacists, however we recognise that some sectors of pharmacy do have issues with recruitment and retention.

2.2   The recently published long-term workforce plan set out NHS England’s aims for the transformation of the pharmacy workforce, through investment in training for more pharmacists along with developing the wider pharmacy workforce to support more effective skill mix.

2.3   The plan however is just the beginning and will take some time to show results. The proper funding of the plans and implementation, including the use of contractual levers for employers will be key to delivering the aims.

2.4   Currently in community pharmacy there are several challenges around recruitment and retention. Consistently, pharmacists tell us in significant numbers about what influences their decisions about where they work and how conditions impact on their health and well-being. [9]

Understaffing

Some pharmacy business owners do not prioritise safe staffing levels, and it appears to be seen as a significant cost saving to operate a pharmacy without the necessary support staff.   Data analysis of the community pharmacy workforce surveys shows that support staffing had been cut by 14% in the period 2017 to 2021. Even more worryingly, the data also showed a reduction of 29% in the number of trainee support staff. [10]

This impacts on patients and the care they receive, the safe and effective operation of a pharmacy, and adds significantly to the workload of the pharmacist, which is often overwhelming. Employer organisations are fully aware of the impact that the cut in staffing has on both retention and recruitment. [11]

Working environments

Many community pharmacy working environments are also lacking in investment from business owners, members tell us about substandard IT systems, breaches of health and safety regulations, unhygienic and infested premises.

Time to learn

Unlike some other healthcare professionals, pharmacists working in community pharmacy do not have protected learning time, so training around the introduction of new services, or professional developments are not supported during working hours. Combined with a lack of adequate breaks this contributes to decisions to resign from their employment and either leave the sector or become a locum where they can manage their own time and choose at which locations to work.

Violence and abuse

The PDA has campaigned consistently against incidents of violence and abuse faced by pharmacists[12]. Community pharmacies are the most accessible part of the NHS, but with that comes a vulnerability to acts of aggression.

2.5   The combined consequences of this are that patients do not receive the best service and pharmacists’ health and well-being is negatively impacted by stress due to workload and working conditions.

2.6   In a written submission to the former Chair of the Health and Social Care Committee, Rt Hon Jeremy Hunt MP, the PDA highlighted data which showed through a variety of data sets the workforce numbers and contributory factors, such as pay rates which influence the workforce agenda. This information is included as Appendix A.

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

3.1   In general, the systems sit in silos. As a working example, when a patient is given a flu vaccination the data relating to this must be uploaded into the patient record in the pharmacy, and then separately to a third-party intermediary who then sends the information to the general practice.

3.2   The issues surrounding interoperability are recognised by the NHS and plans are progressing in certain aspects of this. [13]

3.3   The key to unlocking the full potential of community pharmacists is by ensuring that pharmacists can have full read/write access to patient records. This will ease the ability of suitably trained and accredited pharmacists to be able to run clinics for patients (for example diabetic patient cohorts) within the setting of accessible community pharmacies, as well as for any other interventions to be recorded in a timely and secure way.

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

4.1   At the heart of the 4-year MPharm degree is the learning about every aspect of medicines. This is the unique training that pharmacists bring to the NHS. The biggest innovation with potentially the biggest impact for patients would be the delivery of clinical pharmacy/pharmaceutical care to patients from within the pharmacy.

4.2   From 2026 onwards, every newly qualified pharmacist will be an independent prescriber. It would be unrealistic to expect a newly qualified pharmacist to manage complex casework and run clinics from the very first day of entry to the pharmacist register. However, the direction of travel is clear, and capacity will build at scale from the starting point of today where around 25% of pharmacists have an independent prescribing qualification.

4.3   As the population ages, the number of medicines prescribed increases as does the risk of errors and over-prescribing. Recent analysis shows the cost and impact of these medication errors on the NHS. [14]

4.4   By embedding the provision of clinical pharmacy/pharmaceutical care at the point of supply of medications (the pharmacy) the opportunity to intervene and prevent harm is enhanced. Recent surveys have shown that patients trust pharmacists as much (and often more) than they do doctors.[15]

4.5   This trust relationship is an ideal starting platform to provide the level of clinical pharmacy/pharmaceutical care when needed.

4.6   What do we mean by clinical pharmacy/pharmaceutical care?

Pharmaceutical Care - “A patient centred practice in which the practitioner assumes responsibility for a patients medicines-related needs and is held accountable for this commitment.”[16]

"Clinical pharmacy embraces the philosophy of pharmaceutical care, the primary objective of practice is patient-oriented care. As a discipline, clinical pharmacy relies on in-depth knowledge of therapeutics, clinical experience and expert judgments.” [17]

4.7   This patient-orientated care can be best delivered in an environment that is familiar and accessible to patients – and in this context a local walk-in pharmacy is the ideal setting.

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

5.1   The PDA would advocate that there is a huge opportunity to reconfigure funding arrangements to enhance the proportion that is distributed to the provision of clinical pharmacy/pharmaceutical care in relation to the proportion devoted to the mere supply of medicines.

5.2   However, it would be a mistake to assume that any increase in Government funding will flow through to the recruitment and training of staff or to the reconfiguration of premises. It is therefore essential that funding increases are ringfenced so that they are used for the purpose of healthcare delivery rather than excess dividend extraction by corporate owners.

5.3   A recent precedent for this has been set by the Welsh Government – and whilst we may not agree with the precise detail – we do welcome the linking of increases in funding to that increase being used to provide staff pay increases.[18] It is right and proper that whenever funding increases are offered that pharmacy owners have to agree to how they are utilised.

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

6.1   The PDA regularly hears from pharmacists on the front line in community pharmacy about their experiences and how the medicines shortage situation affects them, and their patients.

6.2   Pharmacists who responded to a PDA member survey about medicine shortages which featured in a Health Service Journal article[19], said they “are spending up to four hours a day sourcing common medicines for patients,” taking them away from patient care amid high demand.

6.3   The causes of medicines stock issues are multifaceted; however, pharmacists are seeking transparency and acknowledgement of supply challenges, along with the adoption of practical solutions at an early stage when shortages occur, so that that they can guide patients and other healthcare professionals on the best course of action.

6.4   Whilst supply issues are often out of the control of the pharmacist, it is those on the frontline that are there to respond to patients needs and, on occasion bear the brunt of their frustration when violence and abuse occurs around a medicine being unavailable. There must be a zero-tolerance approach from pharmacy operators to this kind of behaviour, which is never excusable.

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   Pharmacy owners have hugely cut back on staffing levels. The resultant pressure that this has put on pharmacists has been immense. Whilst we appreciate that pharmacy owners in England have struggled with the reduction in remuneration, many examples of business decisions being prioritised above patient care are still going unchecked.

7.2   The situation in Scotland, where the same large corporations dominate the sector, is similarly dire and the extra funding provided by the devolved Government has not resulted in the universal flow of funding through to the provision of adequate staffing levels, enhanced training and protected learning or an improvement in the quality of premises.

7.3   NHS regional teams seem incapable of ensuring that contractual terms are adhered to, and NHS England has admitted to the Information Commissioners Office that they are incapable of even the most rudimentary data collection, which would form the basis of effective contract monitoring and analysis.[20]

7.4   There needs to be a full-scale independent evaluation of how pharmacy funding is used to ensure that allocated money which is provided for certain activities (such as training) is not being misappropriated.

7.5   The register of pharmacists is growing year on year, with an average annual increase of more than 1,500 to the register (net increase). The biggest barrier to realisation of the potential within community pharmacy is the failure by large corporate owners to invest in support staffing and this has a significant impact on pharmacists.

7.6   Pharmacists are often left to work alone, and their skills and expertise wasted as they get bogged down in non-clinical tasks like checking deliveries. Our annual safer pharmacy surveys have confirmed the issue around lack of support staff and the knock-on consequences of this.[21]

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 distribution of pharmacies across the UK has been in stasis due to the granting of monopolies with the 1986 pharmacy control of entry reforms. In effect this has given protection to many poorly performing operators and created barriers for innovative young entrepreneurs who cannot afford to pay the huge goodwill values being demanded by existing owners to buyout their pharmacy contracts.

8.2   Pharmacy contracts are granted for life, and it would make sense that each contract should be subject to review and renewal after a defined period, ten years for example.

8.3   The whole issue around pharmaceutical needs assessments (PNAs), needs a radical overhaul to ensure that the NHS gets the best value for money. To date there has never been an evaluation of the effectiveness (or otherwise) of PNAs, which are supposed to ensure adequate provision of pharmacies in local areas.

8.4   The recent issue around certain large corporate pharmacy owners withdrawing from the pharmacy market has shone a light on the lack of an evidence based and rational approach to the provision of pharmacies and pharmacy access.

8.5   Research by the Company Chemists’ Association (CCA), which is the umbrella organisation for the large corporate owners of pharmacies in the UK has found that 41% of pharmacy closures have occurred in the most deprived regions of England.[22]

8.6   Pharmacy owners must give notice of a pharmacy closure, however there is no impact assessment or evaluation needed. It is a purely business decision, based on the commercial imperatives of the pharmacy owner.

8.7   As a basic first step, any closure must be impact assessed by the relevant health authority and if needed an open tender invitation be issued for a new operator to take over the pharmacy contract.

8.8   The artificial barriers to open a pharmacy in a location where a previous owner has closed without due process is challenging, especially when the previous owner mounts vociferous opposition to a new pharmacist providing pharmacy services.[23]

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

9.1   Commissioning of services using the community pharmacy network has been patchy and inconsistent. Local schemes lack scale and are started and closed with little incentive for continuity.

9.2   An example of how commissioning can work when the right governance frameworks are in place can be found with the flu service which was first commissioned nationally in England.

9.3   NHS England commissioned a national flu vaccination service in 2015.[24] Every pharmacy in England could take part in the service and there was a national specification underpinning its delivery. From a small and cautious start this nationally commissioned service delivered more than five million flu vaccinations in the 2022-2023 season.

9.4   The year-on-year increase in patients who now choose pharmacy as the place where they can receive their flu vaccination has only been possible with a consistency in service provision, enabling the scaling up to take place safely and effectively.

9.5   One unintended benefit of this extensive network of pharmacists trained to vaccinate was seen with the Covid-19 vaccination programme. Community pharmacies in England have administered more than thirty-four million Covid-19 vaccinations. This was only possible because the pharmacy network existed across England and the readiness of the workforce to deliver a service at the time of national need.

9.6   The PDA’s a Thousand Little Ships policy[25] advocated for community pharmacies to join the NHS programme to add capacity to the system, in addition to the larger Covid-19 vaccination hubs.

9.7   The vaccination example, which can have significant public heath impact, highlights the ability of pharmacists to embrace the delivery of new services and the willingness of patients to have the service delivered by their community pharmacist.

9.8   The right commissioning framework, supported by the suitable skill mix and services which focus on clinical pharmacy/pharmaceutical care of patients could deliver a similar scale of patient acceptance in receiving a range of services from a community pharmacy setting.

The PDA would welcome the opportunity to provide further detail on our submission and to discuss our response to the inquiry with the Committee.

Appendix A

July 2023