Written evidence submitted by Company Chemists’ Association (CBP0021)
Community pharmacy is almost uniquely placed to support the country with the backlog. Examples of how this could work are already in place but need to be rapidly expanded and developed. This includes moving consultations out of A&E, urgent care, and General Practice into community pharmacy, as well as developing the acuity of conditions eligible. Making best use of the pharmacy workforce and their growing clinical expertise is essential, especially in public health and prevention. This is best achieved through standardisation of processes, digital access, and patient pathways. The pandemic has shown the benefit of integrated digital systems, and this improvement needs to be continued.
Community pharmacy has the capacity to significantly impact the backlog of care. What is lacking is investment. Unlike much of the NHS, there has been no new money to support innovation or development. Whilst there are many improvements planned in the current contractual framework, these are all within the existing funding package. To take advantage of the sector’s offer, there is a need to fund the services offered.
Unlike much of the NHS, community pharmacy operates under a very different contractual framework. This means that there is limited control over the incoming workload (as pharmacies are paid by activity) and the majority of ‘normal’ business was completed during the pandemic. A record 93 million prescriptions were dispensed in March 2020, and despite some small delays, much of the agreed actions within the Community Pharmacy Contractual Framework will be delivered as agreed prior to the pandemic.
This means that community pharmacy, is almost uniquely placed as a healthcare provider that has capacity to deliver additional care, with limited backlog from the pandemic. Community pharmacies have previously agreed a mechanism to move care from general practice into pharmacies, through the Community Pharmacist Consultation Service. This is currently being implemented with varying success. With additional funding and support this service could be expanded to wider patient groups, increased numbers, and greater levels of acuity.
The existing frameworks have the potential to transfer up to 20 million appointments per year1 to community pharmacy, freeing up time for the backlog. To realise the full potential of this opportunity there is a need to invest in the community pharmacy network and the supporting digital referral pathways. All NHS settings should be able to refer patients to community pharmacy, from an integrated pathway. Current solutions often add ‘friction’ to the journey. Making efficiencies to the inward referral process (including greater integration with current IT systems) would benefit patients and clinicians. Additionally, there is a need to create digital pathways allowing community pharmacy to directly refer patients onwards, without relying on ‘gatekeeping’ from the already pressured General Practice. Finally, there is a need to support the development of the pharmacist workforce. From 2026 all new pharmacy graduates will be Independent Prescribers, vastly increasing the breadth and acuity of treatment options available to them. There is an urgent need to develop the existing workforce, and then put in place the system to allow the use of these new skills.
From 1st October 2021 all community pharmacies in England will be commissioned to provide Hypertension case-finding. This is an excellent example of how the capacity in community pharmacy can be better used. There are localised examples of diagnostic services, screening, and health checks within pharmacies. The backlog includes regular patient check-ups and previously missed opportunities to identify patient needs. Structured and wide-spread commissioning of community pharmacy across the UK will open up new patient pathways, increasing access and tackling the backlog. This requires new investment but can be done within the extensive network of over 13,000 community pharmacies.
The pandemic has also shown the importance of public health, prevention, and self-care. Community pharmacies saw a significant increase in the numbers of patients accessing their premises, looking for advice from pharmacists and support for their health. These changed patient behaviours should be ‘locked-in’ by encouraging greater use of community pharmacy. This can be done through both public communications encouraging use of existing services (such as influenza vaccinations), as well as a continued development of the prevention work within pharmacies.
Whilst the money provided to NHS England has been well publicised, the financial investment has not materialised in community pharmacy. CCA members have welcomed the agreement to meet direct COVID costs by the government, but additional money has not been forthcoming. In 2019/20 saw an agreement of a ‘5-year deal’, setting funding until 2023/24. This was itself a reduction on previous years. Despite the immense pressures of the pandemic, the backlog of care, and the well-publicised case for community pharmacy to support this – fresh investment has not been forthcoming. With additional resource, community pharmacy can make a significant contribution to the backlog.
The NHS is being reorganised following the Health and Social Care Bill, with a move to Integrated Care Systems (ICSs). These ICSs provide an opportunity to take advantage of a diverse range of care providers. Community pharmacy has the potential to offer significant benefit to local populations, supporting with screening, diagnosis, and treatment of patients – easing the backlog. What is needed is pragmatic, standardised commissioning from ICSs. Too often there are examples of repeated redesign of services, creating variation without adding to patient care. There should be a ‘once for England’ design process with local commissioning of that designed service.
In the medium to long term, there is an opportunity to truly take advantage of the community pharmacy sector. Community pharmacies are known to increase access, tackle health inequalities, and be located within the most deprived communities. Despite good intentions from successive governments, there is yet to be a truly ambitious plan to take advantage of the 11,500 pharmacies in England. By moving large tranches of work into community pharmacy, this will create capacity across the health service. This includes vaccination services, urgent care, screening, and public health interventions such as sexual health, smoking cessation, and cardiovascular care. This requires sustainable funding, initial investment to support the changes needed, and support to overcome structural barriers, such as appropriate-access to patient records.
The pandemic has shown how easily digital technologies can be added to patient care, with several advantages to efficiency and access. What is needed now, is simultaneous recognition of the ‘digitally excluded’ and a commitment to build ‘digital-first’ pathways. Historically, concerns over data security and information governance have hindered joint working. The pandemic has shown this is not necessary, and organisations need the confidence that pragmatic actions in the patient interest will not be punished.
The pandemic has shown how remote consultations can be an effective method of providing care, increasing accessibility, and improving the efficiency of service provision. A key learning is that patient care in the future should be designed with a blended model in mind, allowing the patient and clinician to agree between them the most appropriate way to provide care. Patient circumstances change and it’s important to allow the benefits of remote care, without ignoring the role of face-to-face.
Secondly, there has been a degree of pragmatism throughout the pandemic. For example, early in the pandemic the Summary Care Record was expanded, providing more information to clinicians. This was done swiftly, without overly burdensome administration hurdles to access it. Retaining this collaborative attitude to putting patient care over procedure is essential to take positives from a difficult period.
ICSs have opportunities to commission innovative services and patient pathways. Community pharmacy has often been referred to as an ‘underused resource’ and as we exit the pandemic there are opportunities to change this. To encourage development there is a need to: invest in change, create the environment to allow efficiencies and development, and later a spread of new best practice. Asking any business or organisation to change, whilst maintaining existing service is difficult. Community pharmacies, unlike much of the NHS, are businesses and require both investments to implement changes and the security of long-term investment. This is further complicated by a strict regulatory environment, designed for practice many decades ago. There are existing workplans to make some changes to this, which should be prioritised now the pandemic pressures are easing.
Every ICS will undoubtedly be looking for ways to improve, innovate, and capture the learnings of the pandemic. Many community pharmacies operate across boundaries, or service patients from wide geographies. To prevent significant inefficiency and administrative burden, as well as a post code lottery, there is a need for frameworks of care. Core elements of governance, data protection, training etc., should remain consistent across the country. Within these frameworks, specific interventions can be designed matching the needs of the local population. This also increases efficiency for commissioners, preventing the need for re-writing guidance. Once successful innovation has been identified there needs to be a clear route to sharing this across the country. There are examples of excellent service initiatives that remain isolated to small parts of the country. Ideally, new ideas are developed and trialled locally, before being commissioned nationally. Certainly, it should be an assumption that once a service is commissioned in multiple ICS areas, the service should be brought into a national commissioning framework.
About the Company Chemists’ Association (CCA)
Established in 1898, the CCA is the trade association for large pharmacy operators in England, Scotland, and Wales. The CCA membership includes ASDA, Boots, Lloyds Pharmacy, Morrisons, Rowlands Pharmacy, Superdrug, Tesco, and Well, who between them own and operate around 6,000 pharmacies, which represents nearly half of the market. CCA members deliver a broad range of healthcare and wellbeing services, from a variety of locations and settings, as well as dispensing almost 500 million NHS prescription items every year. The CCA represents the interests of its members and brings together their unique skills, knowledge, and scale for the benefit of community pharmacy, the NHS, patients, and the public.