Written evidence submitted by the Company Chemists’ Association (FGP0327)

 

About the Company Chemists’ Association

 

Established in 1898, the Company Chemists’ Association (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.

 

About our response

 

The CCA has chosen to respond to selected questions in the call for evidence, particularly those that are pertinent to community pharmacy.

 

Executive summary

 

 

The CCA’s response

 

What are the main barriers to accessing general practice and how can these be tackled?

 

 

The Government and NHS England’s plan encourages all GP practices to sign up to the Community Pharmacist Consultation Service (CPCS) by 1 December 2021 and states that participation is a condition of a practice being able to benefit from the Winter Access Fund. The CPCS allows GPs to refer patients with minor illnesses on to community pharmacies. However, NHS England (NHSE) are currently recruiting community pharmacists into Primary Care Networks (PCNs). NHSE want to recruit 7,500 pharmacists into PCNs by 2024 and have recruited nearly 3,000 so far[i] - with this cohort recruited from community pharmacy and secondary care. This means that workload is being moved away from where the NHS is recruiting pharmacists to, and into the very place they are taking them from. We are therefore concerned about community pharmacy’s ability to deal with increased workload via more CPCS referrals in the long-term, given the acute workforce crisis the sector is already facing.

 

Pharmacy teams can support GPs and hospital teams in alleviating pressure on these parts of the system. The Pharmaceutical Services Negotiating Committee’s (PSNC) 2021 Pharmacy Advice Audit found that informal consultations provided by pharmacists and their teams save more than 24 million GP appointments every year. The community pharmacy sector needs additional investment to ensure it continues to alleviate pressure off general practice.

 

During the winter, when waits and pressures on GP practices are at their highest, we see increased patients across all primary care, including pharmacy. Whilst initial Government plans focus on general practice there is nothing to acknowledge the increased pressures on community pharmacy. This includes the increasing number of walk-in patients who cannot access GPs and have not necessarily been referred via CPCS. Patient behaviour is changing because of the CPCS, the Covid-19 pandemic and the accessibility of community pharmacy which means that community pharmacy is increasingly being seen as a first port of call for some patients. This increased workload, however, needs to be recognised and supported through additional investment to ensure that patients who do turn to community pharmacy are helped, and do not end up merely returning to general practice.

 

We urge the Government and NHSE to better involve community pharmacy in winter planning and for a public information campaign to highlight the typical services, care and support patients, especially those with minor ailments or in need of healthcare advice, can expect from their local pharmacy.

 

How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

 

 

We note that there have been recent improvements to align incentives between GP and pharmacy contracts, for example in terms of the flu vaccination service, and to drive collaboration. However, the current PCN system creates some barriers to integration. For example, pharmacies, unlike General Practice, must currently pay VAT on services which means they have to charge 20% more – thus restricting the ability of community pharmacy to provide services to the NHS competitively. There are also many costs associated with providing healthcare which are recognised unevenly by the NHS – for instance business rates and IT costs are covered by the GP contract but not the pharmacy contract.

 

The current systems lack coordination due to the ongoing recruitment of the pharmacy workforce by NHSE of pharmacists into PCNs. This is making it harder for community pharmacies to recruit pharmacists and the workforce supply issues as well as inflationary pressures on salary is also driving up locum rates as well. This is compounded by the fact that community pharmacy has fixed funding under the Community Pharmacy Contractual Framework (CPCF) which came into force from October 2019 for a five-year period - before the pandemic and before the UK left the EU and not accounting for inflation since.

 

We recommend that the government and NHSE work with both community pharmacy and GPs to develop nationally-agreed frameworks and guidance, allowing PCNs to commission community pharmacy. There are priorities within PCNs that are not being met due to ongoing pressures. PCNs need direction and flexibility in using all available resources to deliver patient care, through a mixture of different employment and contractual models. This would ensure that pharmacists are deployed at the right time and right place for the healthcare needs of their local community.

 

The Secretary of State for Health and Social Care has outlined his vision for a ‘pharmacy first’ model in England, whereby patients with minor illnesses receive treatment at their local community pharmacy. We support the Health Secretary’s desire to see a ‘pharmacy first’ model in England - however, this service would need to be agreed and appropriately funded.

 

 

Despite high hopes we have not seen any substantive evidence that the development of PCNs has improved the delivery of proactive, personalised, coordinated and integrated care nor has it reduced the administrative burden on GPs. We appreciate that some plans will have invariably been delayed due to the Covid-19 pandemic. The success of the Covid-19 vaccination programme is one example where collaboration across PCNs has worked well, and community pharmacy has delivered alongside these arrangements.

 

Additionally, in 2020, NHSE and the British Medical Association (BMA) published the ‘Update to the GP contract agreement 2020/21 – 2023/24’[ii] through which PCNs would be guaranteed funding for up to an additional 26,000 staff by 2023/24. This has led to the recruitment of a number of important roles and delivered some examples of better clinical practice. However, we have not seen a robust evaluation of the return-on-investment of professionals that have been recruited into PCNs via the Additional Roles Reimbursement Scheme (ARRS) funding.

 

We would urge NHSE to evaluate PCNs and provide evidence of the value of the roles recruited through ARRS funding.

 

 

Examples of partnership working are bespoke offerings, built upon local relationships. This approach fails to take advantage of the scale offered by community pharmacy whilst creating a 'postcode lottery' of care. The lack of commonly understood contracting mechanisms, shared care agreements and frameworks adds bureaucracy that often is not possible within local PCNs.

 

However, some GPs have benefited from the roll-out of the Discharge Medicines Service. Following a successful pilot, NHS Trusts can refer patients who would benefit from extra guidance around new prescribed medicines for provision of the Discharge Medicines Service (DMS) at their community pharmacy. The service has been identified by NHSE’s Medicines Safety Improvement Programme to be a significant contributor to patient safety at transitions of care, and by reducing readmissions. DMS means GPs do not have to confirm a patients existing medication when they are discharged.  The pharmacy confirms what repeat prescriptions need changing, if any, and the GP does not have to follow up with the patient to ensure they have the right medication, delivering significant administrative savings.

 

For every 10 DMS consultations, there is one avoided admission and on average 16 bed days are saved. Despite the clear benefits of this service, volumes remain low. Pharmacies can only act upon referrals from secondary care teams, which in September 2021 totalled 7,981[iii]. At less than 1 per pharmacy per month, the true benefits of this service are not being realised. This is further exacerbated by the significant variation in referrals from different ICS areas. Referrals are also of variable quality, in terms of the data received, and come on a whole array of systems from across the country which makes it more difficult for community pharmacy to manage. DMS would benefit from support to secondary care to fund electronic referral systems, incentivise referrals, and publicly sharing referral rates from individual hospitals.

 

There is much to be learnt from the Scottish approach of identifying streams of workload that do not require particular skills of GPs and can be moved to community pharmacy, thus freeing up general practice capacity.

 

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[i] See page 5, paragraph 9 of ‘Our plan for improving access for patients and supporting general practice’, 14 October 2021 available here: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/10/BW999-our-plan-for-improving-access-and-supporting-general-practice-oct-21.pdf

[ii] Update to the GP contract agreement 2020/21 – 2023/24, 6 February 2020. Available here: https://www.england.nhs.uk/wp-content/uploads/2020/03/update-to-the-gp-contract-agreement-v2-updated.pdf

[iii] See ‘Discharge medicines service data – September 2021’ (excel file) available here: https://www.nhsbsa.nhs.uk/prescription-data/dispensing-data/nhs-discharge-medicines-service

 

Dec 2021