Written evidence submitted by the Pharmaceutical Services Negotiating Committee (WBR0089)
- The Pharmaceutical Services Negotiating Committee (PSNC) represents the 11,400 NHS community pharmacies in England. We are recognised by the Secretary of State for Health and Social Care as the body that represents NHS pharmacy owners.
- Our goal is to develop the NHS community pharmacy service, and to enable community pharmacies to offer an increased range of high quality and fully funded services; services that meet the needs of local communities, provide good value for the NHS and deliver excellent health outcomes for patients.
- PSNC is very concerned about the resilience of community pharmacies and all those working in them as we move through this second COVID-19 peak. In this response we first outline the increases in workload that community pharmacy teams have had to manage throughout the pandemic – these have been significant. We then look at the negative impact this has had on workforce stress and resilience, and finally we outline the support that we believe the community pharmacy sector now needs to cope though the second wave of the pandemic.
Impact of COVID-19 pandemic on demand for pharmacy services and workload
- When the COVID-19 pandemic first began to peak in England, community pharmacies across the country saw increased demand for medicines and healthcare advice. In part this was due to a sudden increase in prescription volumes in March 2020, a record 93 million prescription items were dispensed.
- Pharmacy teams also reported a steep increase in the volume of phone calls being received, with many people asking to have medicines delivered to them and lots of confusion where GP practices had directed people to pharmacies for their prescriptions but these needed to be requested first from the practice. One independent contractor (pharmacy owner) remarked that when national lockdown first began, the phone would not stop ringing. He said that while this workload has eased slightly now, the pharmacy is still experiencing a 40% increase on pre-COVID activity (see case study B).
- Demand for healthcare advice from pharmacies has also been high. PSNC carried out an audit to try and quantify the number of informal patient consultations happening in pharmacies in England. In June and July 2020, more than 9,400 pharmacies in England took part, each choosing one day on which to record their patient consultations. In total 198,043 patient consultations were recorded by the 9,441 pharmacies, indicating that the average pharmacy carries out around 15 patient consultations per day. The consultations were all conducted outside of specifically commissioned services.
- Extrapolating the results of this national audit, if the proportion of patients seeking advice who said they would have visited their GP practice if the pharmacy had not been there holds, and pharmacy advice were taken away, this would result in approximately 492,000 additional GP appointments each week, or 65 appointments in each GP practice each week in England. While some funding is provided for pharmacies for supporting people with ‘self-care’ through the Community Pharmacy Contractual Framework, we believe this is no longer sufficient to cover the considerable costs of this increasingly important part of pharmacies’ work.
- Indeed, the pandemic has altered the public’s perception of community pharmacies, with people now more likely to seek help from them – a survey by the Proprietary Association of Great Britain, which was published in July 2020, showed that since the pandemic 51% of respondents who would previously have sought a GP appointment as their first option were now less likely to seek a GP appointment as a first port of call, and 31% of people who would not historically have sought advice first from a pharmacy, were now more likely to do so.
- Pharmacy teams have also been impacted as local GP practices changed their approach to patient care during the pandemic. It has become increasingly difficult for pharmacies to contact GPs and other healthcare professionals and this can create delays for patients who have queries about the supply of their prescriptions or are expecting them earlier than they can be prepared. One pharmacy contractor commented that often his staff members spend hours on the phone trying to get through to general practices and that he could theoretically employ a full-time member of staff simply to communicate with the local practice (see case study B).
- We know that patients displaced from GP practices are walking into pharmacies for advice on a range of health conditions. Furthermore, with dentists and opticians also unable to see patients in the volumes they used to, community pharmacies are experiencing increasing numbers of patients presenting with optical and dental problems. We have heard a report of a pharmacist who was met by a patient who broke down in tears in his pharmacy after being told by the dentist that she would have to pull her own son’s tooth out. Another pharmacist reported that a patient presented with a mole which needed checking. They had been unable to get through to the GP practice over the phone and had tried over 60 times. Although these are individual examples, they are indicative of some of the extra workload that pharmacy teams have to take on during the pandemic, and they can be distressing for pharmacy teams.
- The impact of these increases to workload have been worsened by the need for many members of pharmacy staff to self-isolate, in line with national Test and Trace guidance. Of course, staff absence has an impact on the remaining workforce in pharmacies, increasing the pressure on them even more. Where available, locums can be brought in, but this has an extra cost, and independent contractors say that communicating with their teams is much harder now with social distancing and other safety measures in place. Constant changes to team structures can be hard for staff to keep up with and has a negative impact on morale (see case study A).
- In short, although community pharmacies have done all they can to rise to the challenges of the pandemic, for most this has been a significant challenge and the increased workload feels unsustainable for many people. Energy levels are low, and without any clarity from HM Government about whether their COVID-19 related costs will be covered, businesses are also struggling to give their staff the support they need to cope with these difficult times.
Impact on staff morale and stress
- Prior to the pandemic, pharmacy teams were experiencing stress and burnout. A survey by the Royal Pharmaceutical Society showed that 80% were at high/very high risk of burnout due to exhaustion. These results were published in December 2019, well before COVID-19 impacted the UK.
- The COVID-19 pandemic has undoubtedly tested the resilience of community pharmacy staff. As a consequence of the unpredictable increases to their workload pressures, many pharmacists tell of gruelling work schedules which are affecting their families and their health and are unsustainable from a health perspective long term. Independent community pharmacy owners often report that they find themselves trying to juggle too many things, as evidenced in one of our case studies, where an independent pharmacy owner described how he has taken only four days off since the pandemic began (see case study A). But larger businesses and their teams also face significant challenges and stresses.
- Community pharmacy teams across all businesses talk of a deepening sense of anxiety and fear; they say that morale is at an all-time low as they struggle to keep up with demand and they talk of the abuse that they suffer daily from members of the public who are angry, frightened and do not understand the challenges facing pharmacy teams. A large chain of independent multiple pharmacies conducted a survey of 1,395 pharmacy staff, of which 78% said they would find free access to independent mental health counselling helpful.
- Community pharmacy staff have been concerned about coming into work and putting themselves and their families at risk of contracting COVID-19. Many had difficulties sourcing PPE at the beginning of the pandemic – and those who did, often paid high prices for masks and gloves. This has all added to the stress of working on the frontline during a pandemic.
- Unfortunately, pharmacy staff have also reported many instances of abuse from customers. One contractor noted that two staff members have broken down crying due to the way they have been spoken to by members of the public (see case study B). While there has been lots of appreciation from patients, he said there has been a shocking increase in nasty behaviour and described two particular incidents where the pharmacy team experienced racial abuse, both of which occurred early on in the pandemic, when workload was high, and people were particularly anxious. On one of these occasions, the GP practice had not yet sent the prescription through, so it wasn’t ready. The patient got angry and screamed racial abuse at staff, even though the pharmacy were not at fault. He said: “Events such as this affect the mental health of the team - they don’t know whether the next person who walks in will be pleasant or abusive.”
- Pharmacists working in a range of pharmacy businesses have told similar stories. Some pharmacy contractors have reported that their staff are experiencing abuse from the public on a daily basis, many of whom are stressed and frustrated, so vent their anger at who they can. A large pharmacy group reported that one of their members had eggs thrown at the pharmacy by a disgruntled patient, and they told of many more accounts where pharmacy staff had been subjected to verbal attacks and threatening behaviour (see case study C).
- Morale has also been affected by uncertainties about what is expected of pharmacies. For example, to accommodate increased demand, pharmacies were required by NHS England & NHS Improvement to open during the Easter Bank Holiday weekend. In usual times, many pharmacies generally close over this period, however, to help ensure patients were able to maintain their access to medicines in difficult times, they remained open. Slow NHS decision making on this topic meant that these decisions were implemented very late and gave pharmacy teams little time to prepare and ensure staff were in place, adding pressure to an already overstretched workforce. Of course, many pharmacy staff also missed out on a break which they may urgently have needed.
- In summary, many community pharmacy teams have suffered from considerable work-related stress during the COVID-19 pandemic and they are approaching burnout. Pharmacy businesses are doing all they can to support staff, but they are facing considerable financial and operational challenges, and uncertainty about the future, which does not facilitate this. The two largest pharmacy chains have announced significant cost-cutting and reorganisation measures and this leads to an additional stress for pharmacy teams, as it leaves them uncertain about the security of their roles in the long term.
Measures required to tackle and mitigate the causes of workplace stress
- There are several ways in which the resilience of community pharmacy teams could be strengthened.
- First and foremost, the sector needs clarity on COVID-19 related funding, and for all costs arising from the pandemic to be covered, in line with HM Government promises. Adequate financial support for pharmacies would help businesses owners to juggle some of the many operational challenges they face and also give certainty and reassurance going into the next COVID-19 wave in England.
- At the moment, this clarity and COVID-19 funding is not guaranteed. Many pharmacies have taken on significantly higher costs during the COVID-19 pandemic to cover rising staffing costs (e.g. where team members have had to isolate) and all the safety measures required to keep people safe, such as PPE, cleaning, and social distancing measures. These costs have been significant and coupled with a reduction in income from over-the-counter sales and services, this has left many pharmacies facing serious financial challenges.
- Some government support has been provided to help ease pressure on the sector, but it has not been sufficient. In the early months of the pandemic, HM Government agreed to inject urgent funding injections into the sector, worth a total of £370m, in order to ease cashflow. However, these payments were an advance and they will need to be paid back. Many pharmacies simply will not be able to afford this and it will exacerbate financial pressures.
- In addition to adequate funding, the sector needs HM Government and NHS help to set patient expectations about what services they can receive from pharmacies and to remind the public that pharmacy teams are healthcare professionals, and they should not be subjected to abuse.
- Finally, pharmacies need to continue to have access to adequate PPE, and they also need to have rapid access to COVID-19 testing for pharmacy teams and to be treated as healthcare settings by all NHS Test and Trace operators. Where this does not happen and a staff member tests positive for COVID-19, this can mean that despite the many measures in place to mitigate the risk of infection spreading (as is the case in all healthcare settings), pharmacies can be told to close at short notice, putting services and local patients at risk. Better national coordination and assurance that all pharmacies will be treated as healthcare settings, would be helpful.
Case Study A: Independent pharmacy owner (Greater Manchester)
As a pharmacy owner, A is facing a combination of pressures at the moment, including running his business and managing finances, responsibility for looking after his staff and meeting the needs of the patients who enter the pharmacy. But when asked about how his personal life has been affected, he said: “I can’t afford to stop and think about how this is impacting me personally”.
Since the beginning of the pandemic in March, A has barely taken any time off: “I have had a minimum of two days off, perhaps a maximum of four”, he says. He noted the added pressure of needing to look after a team of staff, which becomes more difficult when you do not have the time to look after yourself.
A says it is a lonely time for many pharmacy owners, as very few people understand or care about the pressures they face. He says: “There seems to be a perception we are successful business owners, many with multiple sites, and therefore must be thriving and making lots of money during the pandemic. This is far from the truth.”
But financial concerns are not the only problems pharmacy owners are facing at the moment. Looking after a team of staff during the pandemic has brought its own set of challenges. A says that many of his staff members have been under pressure at home, particularly those with young children who have needed to source childcare where schools have been closed. “Some have not been able to access normal childcare services and the schools were shut for some time, leaving some staff spending £35 a day for childcare for three children,” says A. Many of his team have also been affected by personal problems throughout the pandemic, where family members have become ill or are at-risk, all of which adds an extra layer of pressure to what has been demanding work on the NHS frontline.
A’s team has also had to adapt to deal with difficult customers, some of whom have become abusive and threatening if their prescriptions are not ready when they want them. Often this is not in the pharmacy’s control – the GP surgery may not have sent the prescription across, or there could be supply issues with a medicine. He also noted that during the pandemic it has become increasingly difficult to obtain stock at the right price.
Greater Manchester has now been placed into Tier 3 lockdown restrictions. A says that because of this, many patients who were previously shielding are automatically choosing to self-isolate, meaning that many people are expecting the pharmacy to be able to deliver prescription medicines to their homes. At the beginning of the pandemic, government funding was made available to help deliver prescriptions to those who were shielding, but because the shielding programme has formally ended, this service is no longer funded. A says: “It is hard to explain to patients that we cannot afford to provide this service, especially when they became accustomed to it during lockdown.”
Case study B: Independent pharmacy owner (Kent)
B noted that when national lockdown first began, the phone would not stop ringing: “We would hang up one call and immediately the phone would start ringing again. The pressure has eased slightly since then, although we are still experiencing a 40% increase on pre-COVID activity.”
He found there had been some problems communicating with local GP practices: “A lot of local practices have had workforce issues and many are hiring locums to help, but some are not trained on electronic prescriptions, so errors happen, and prescriptions don’t arrive fast enough, meaning everything is slower than usual.” B commented that often his staff members spend hours on the phone trying to get through to the GP practices and that he could theoretically employ a full-time member of staff simply to communicate with the local practice.
During the heatwave in the summer, some suppliers were unable to deliver certain medications due to lack of cold chain storage. B said: “This was out of our control, but we still faced complaints from the public as to why their prescriptions were not ready.” Two staff members have broken down crying due to the way they have been spoken to by members of the public. B added: “Just because we are frontline staff, doesn’t mean we are immune to the mental strain of the pandemic. There has been lots of praise from patients and many have been appreciative of our efforts, but there has been a shocking increase in nasty behaviour.” He described two particular incidents where the pharmacy team experienced racial abuse, both of which occurred early on in the pandemic, when workload was high, and people were particularly anxious. On one of these occasions, the GP practice had not yet sent the prescription through, so it wasn’t ready. The patient got angry and screamed racial abuse at staff, even though the pharmacy were not at fault. B said: “Events such as this affect the mental health of the team - they don’t know whether the next person who walks in will be pleasant or abusive.” Some members of his team have moved on and no longer work at the pharmacy due to the pressures faced, which he is concerned about: “We are losing experienced, trained members of staff”.
He also remarked that patients who were shielding during lockdown have struggled to understand that the pharmacy can no longer deliver their prescriptions to their homes free of charge, as the funding for this has been taken away. This is an extra expense to contractors which is not funded.
Case study C: Larger pharmacy group
We spoke to a large pharmacy group, who described some of the pressures their teams have faced throughout the pandemic. They noted that in March there was a dramatic increase in prescription volumes, creating unprecedented workload, while in April and May, staff absences due to illness had significantly increased. They said in the early stages of the pandemic, teams would describe how they would go above and beyond to provide support to patients during a time of great uncertainty, from comforting elderly patients struggling with loneliness, to delivery drivers raising the alarm when spotting a patient slumped at the door. Although these are individual stories, the group noted that patients have become used to this level of care and attention, and now six months into the pandemic, this ‘extra mile’ has become the norm.
But despite hearing many positive stories about how the workforce has risen to the challenges of the pandemic, the group’s pharmacy teams have also reported an increase in antisocial behaviour from the public; they told how one pharmacy had eggs thrown at it by a disgruntled patient, while break-ins have quadrupled over the last three months. These types of events merely add to the pressures felt by the workforce, indeed, the group carried out a survey of 1,395 pharmacy staff, of which 78% said they would find free access to independent mental health counselling helpful.
As we approach the winter, colleagues are physically exhausted from the strain of the last few months, the group said, and quite how they will manage the next peak is unknown.