Written evidence submitted by The National Pharmacy Association (CLL0099)

1.Executive Summary

1.1              The National Pharmacy Association represents the majority of family-owned pharmacies across the UK.  

1.2              We wish to focus our remarks on the UK’s prior preparedness for a pandemic.

1.3              Community pharmacy is the most visited of all settings in which NHS services are provided.  68% of the population has visited a pharmacy since March 2020, i.e. since the first national lockdown came into effect.

1.4              The number of pharmacies closing due to chronic underfunding and rising costs has been accelerating.

1.5              Underfunding that part of the NHS which is the most accessible for face to face care, including in deprived areas, is no way to prepare the health service for a pandemic.

1.6              The response to the pandemic in primary care has also lacked coherence due to institutional side-lining of community pharmacy over many years.

1.7   Before the next public health crisis hits the UK, there should be in place:

1. At least the same number of community pharmacies as we have currently in the network, and ideally a community pharmacy in every neighbourhood
2. Independent Prescribing pharmacists in every pharmacy, to make the experience of obtaining  medicines more convenient for patients; this is especially important when the system comes under the kind of stress we have seen throughout 2020 with coronavirus.
3. Sufficient IT interoperability to allow pharmacies, GPs and hospitals to give an integrated response to any future pandemic.
4. Funding sufficient to sustain these developments – and a mechanism for funding fairness that takes into account the NHS position as a near monopoly commissioner of community pharmacy services.
5. A senior manager on the board of the NHS with direct experience of delivering community pharmacy services.  

1.8              There is now a window of time to develop community pharmacy as the default starting point for most patient journeys, within integrated local care systems. This will help the NHS recover from the trauma of COVID-19, bring lasting benefits and prepare the health system for the next public health crisis whenever it may occur – as sadly it inevitably will at some point.

2.The National Pharmacy Association  (NPA)

2.1              The NPA is a membership body which represents the vast majority of independent community pharmacies in the UK.  We count amongst our members independent regional chains through to single-handed independent pharmacies. This spread of members, our UK-wide geographical coverage, and our remit for NHS and non-NHS affairs means that we are uniquely representative of the independent community pharmacy sector.  In addition to being a representative voice, we provide members with a range of professional services to help them maintain and improve the health of the communities they serve.

2.2              Should the committee require any more detailed information from the community pharmacy perspective, the NPA can provide a witness for any sessions of the committee. To arrange this, please contact Helga Mangion, Policy Manager

3.The role of Community pharmacies in the pandemic

3.1              Throughout the COVID19 crisis, local community pharmacies have risen to the challenge of staying open and continuing to see patients, even whilst other parts of the health system went behind closed-doors. Pharmacy teams have put themselves at risk every day to help keep Britain healthy.

3.2   As well as supplying vital medicines to millions of people, pharmacists have provided urgent care, given expert medicines advice to people with long term conditions, advised on common illnesses and kept pressure off GPs and hospitals.

3.3   The vast majority of the UK’s adult population has visited a pharmacy since March.

• 68% of those responding to an NPA online survey carried out in early November said they had visited a pharmacy at least once in this period.
• 35% had visited a pharmacy at least once due to their GP being unable to see them because of COVID safety measures at the surgery.
• 89% of people believe pharmacies are playing an essential role in the COVID19 crisis, according to a consumer survey carried out in June.

3.4   Coronavirus has had the effect of widening health inequalities. Pharmacies are accessible to people in the UK’s most deprived neighbourhoods across the country, and can play a significant role in restoring the health and wellbeing of people in those areas. The inverse care law – where the provision of services is inversely proportional to the health need – is widespread. Community pharmacy, however, bucks the inverse care law and reaches into deprived neighbourhoods to provide care to the people who need it most.

4.Location/accessibility of pharmacies

4.1   Given the experience of the current pandemic, in order for the health service to be resilient in the face of future pandemics, there ought to be at least the current level of public access to pharmacies. The NHS would have been overwhelmed in 2020 without pharmacies absorbing demand for advice and treatment. It has long been cited that approximately 1.6 million people a day visit a pharmacy for healthcare.  During the pandemic they have delivered at least a further 20 million interventions given by GPs in normal times (NPA data, November 2020).

4.2   Fewer than 10% of the pharmacy consultations recorded in an audit of 9400 pharmacies (PSNC, July) resulted in patients being referred to their GP, yet 49% of patients said that if the pharmacy had not been there, they would have visited their GP. A further 5.7% would have visited A&E / walk-in centre, which would result in an additional 57,000 appointments per week. Extrapolating the results of this national audit, taking away pharmacy advice would result in approximately 492,000 additional GP appointments each week or 65 appointments in each GP practice each week in England, according to PSNC.

5.Primary care workforce/Prescribing pharmacists

5.1              The system of medicines supply has come under extreme pressure at peak moments of the COVID-19 crisis.  Many patients have found themselves pushed from pillar-to-post because the pharmacist cannot supply a particular medicine and needs to refer back to the GP for an alternative prescription.

5.2              Ahead of the next epidemic or pandemic, there should be independent prescribing pharmacists in every pharmacy, so that this situation need not arise again. 

5.3              As well as increased convenience for patients, prescribing pharmacists take workload relating to minor illnesses and stable long-term conditions off GPs and release capacity throughout the primary care system.

6.IT to facilitate an integrated response to future pandemics

6.1              There needs to be sufficient IT interoperability to allow pharmacies, GPs and hospitals to give an integrated response to any future pandemic.

6.2              Some infrastructure has been put in place, which helped community pharmacy to maintain essential services during the pandemic. For example, the Electronic Prescription Service (EPS) allowed community pharmacies to receive prescriptions electronically from GP surgeries, avoiding the risk and logistical challenges of collecting paper prescriptions. In recent years, community pharmacy has been given access to the Summary Care Record and this provided some support to pharmacists dealing with a broader scope of clinical issues. All community pharmacies have NHS mail which supports secure communication with other parts of the NHS.

6.3              However, the uptake of Repeat Dispensing has been low. Had electronic Repeat Dispensing been in place in more places community pharmacists would have been able to play a more proactive role in managing the medicine supply for patients. This would have reduced GP workload, been more convenient for patients and support workload planning within community pharmacy.

7.Funding 

7.1              Despite their vital work on the NHS frontline during the coronavirus pandemic, pharmacies across England are under threat.

7.2              Many pharmacies could soon vanish forever due to underfunding, according to a report from Ernst and Young (EY). They say nearly three-quarters of family-owned pharmacies in England could be forced to shut their doors over the next four years.  EY found that pharmacies are under-funded to the tune of £497m – with 72 percent forecast to be loss-making within four years if the current funding arrangements continue unchanged.

7.3              If pharmacies close, this will limit access to health services in villages, towns, urban areas and in rural communities.  The inevitable result will be unemployment and more pressure on the NHS as people turn to GPs and A&E departments for the help that they can currently get conveniently in pharmacies.  Importantly for this Inquiry, it will also make the health service less resilient against the impact of future shocks.

7.4              As well as recommending an uplift in funding, EY also recommends a mechanism for funding fairness that takes into account the NHS position as a near monopoly commissioner of community pharmacy services.

8.System Leadership

8.1 At the outset of the pandemic, the NPA was part of the clinically led stakeholder group addressing the then emerging issues associated with Covid-19. It was an opportunity for the medical, nursing, dental and pharmacy professions to come together and share their expertise and experience to address issues as they were emerging. Key successes include the medicines delivery service and the recognition of additional support required by the new categorised shielded patients.

8.2              However, this is a relatively rare example of community pharmacy being engaged in health service planning.  The response to the pandemic in primary care could have been more coherent were it not for the institutional side-lining of community pharmacy over many years, at both local and national level.

9. Other remarks

9.1 Personal Protective Equipment

At the beginning of March, the National Pharmacy Association raised concerns in regards to the availability of Personal Protective Equipment. Community pharmacy was considered a private sector provider and hence was advised to order these products from wholesalers, who did not have adequate stock available. At the time NPA members informed us that the same masks were having to be used repeatedly over a number of weeks. Only six months later did the ordering portal become available to community pharmacy.

9.2 Test & trace

The lack of available testing raised a number of workforce issues as members of the pharmacy teams had to self-isolate for fourteen days unaware of whether they had the virus or not.

9.3 Local communication

Local agencies such as the drug and alcohol teams instigated new pathways and patients’ treatment without the involvement and consultation of community pharmacists and their teams. A number of pharmacists and their teams needed to react to an instant change in the prescribing and administration of substance misuse, which could have led to unintended consequences on the service user. For example, in increased likelihood of non-compliance with drug regimen.

10.Conclusion

10.1              Community pharmacies are a local lifeline – and have proven themselves to be such during the COVID-19 pandemic. They provide vital health and social care in communities across the land, including the most deprived neighborhoods.

10.2              Yet many family-owned pharmacies in England could be forced to shut their doors permanently, due to chronic underfunding and the costs of meeting spiralling demand during COVID-19.

10.3              This is no way to prepare for a future shock to the health service. A change of course is urgently needed, with sustained investment in pharmacy infrastructure, workforce and services.