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Dispensing with pharmacies

Dispensing with pharmacies

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The financial cuts to pharmacies is damaging to the profession to say the least. But it also has an impact on the whole of primary care and patients 

Community pharmacy has, so far, been immune from austerity, but it was only a matter of time before this changed. In a letter sent to the Pharmaceutical Services Negotiating Committee (PSNC) late last year, the Department of Health (DH) proposed a 6% cut in community pharmacy funding for 2016-17, reducing it from £2.8 billion to £2.63 billion.
The announcement comes at a time where community pharmacy is playing an increasingly important role in reducing the burden on primary care, and as part of the Five Year Forward View.
It has been met negatively by the pharmacy sector. Keen to show that it is listening, the DH has extended the consultation deadline until the end of May. But, the feeling is the cuts are coming – and this could be just the beginning.

Sector expansion
Dr Keith Ridge, NHS England’s chief pharmaceutical officer describes how the number of pharmacies has grown by 20%. In plain terms, the sector has grown from 9,748 pharmacies in 2003 to 11,674 in March 2015.
Dr Ridge went on to claim that research undertaken by NHS England and the DH shows that more than 40% of pharmacies are ‘clustered together’ – within a 10-minute walk of one another. Take a trip to rural communities however, and the situation is likely to be very different.
In the past the government has played a key role in encouraging this expansion. Deregulation, aimed at increasing competition and choice, has seen the number and type of pharmacies increase, with ‘multiples’ like Boots, Lloyds, Superdrug and supermarkets keen to grab a slice of the market.
With the average community pharmacy costing an estimated £220,000 a year, are these cuts the DH taking an opportunity to reign in a sector that’s out of control? Dr Ridge believes so, controversially asserting that there are “3,000 too many pharmacies”.

Coordinated response
“The increase in numbers of pharmacies has clearly been matched by customer demand,” claims Sandra Gidley, chair of the Royal Pharmaceutical Society. Gidley points to the 55% increase in the number of prescription items dispensed in the decade between 2004 and 2014 as evidence.
The feeling from Gidley and the PSNC chief executive Sandra Sharp is that these proposed cuts come at a time when the sector is beginning to grow in importance, and could halt it in its tracks. “The NHS speaks of this potential to develop community pharmacy services; but their proposals do not detail how this could be achieved,” she adds. Inevitably, Gidley believes that these cuts will increase demand on GPs and A&E departments already struggling to cope.
It’s a view shared by Dr Joe McGilligan, former chair of NHS East Surrey Clinical Commissioning Group (CCG) and chair of The Commissioning Review: “Pharmacists get to know patients and become valuable to us as colleagues.” It’s a positive working relationship that benefits both the GP and the patient. “You develop relationships with them, they get to know your prescribing habits and can help to identify issues with patients.”
Calling the proposed cuts “short-sighted,” McGilligan believes that smaller, local community pharmacies will be disproportionately affected. “The knock-on effect will be problematic.” He adds that it’s likely to be CCGs and GPs that will be called upon to fill the gap in provision.

Local impact
Michael Keen has been involved in the pharmaceutical industry for more than 40 years. Currently the CEO of Kent LPC, Keen describes the county fondly, tracing its border and pointing out rural areas, and those areas of poverty and deprivation that he feels could lose out in the changes.
“The cuts are counterintuitive,” Keen claims, pointing out how community pharmacy has been increasingly playing a part in the government’s plans. When this point is put to Ridge, he’s unequivocal. “Everyone will still be able to access a pharmacist,” he states. Dr Ridge describes how funding will be pushed to those areas and pharmacies that need it. In their letter to the PSNC, the DH claims it will “consult on the introduction of a Pharmacy Access Scheme”.
The DH promises to identify those pharmacies that are “the most geographically important for patient access, taking into account an isolation criteria based on travel times or distances, and also population size and needs.” It’s encouraging to see this commitment to tackling inequality, but it remains to be seen how this will work in practice.
Dr Ridge outlines a vision for a more modern pharmacy sector, including the increasing use of online dispensing, collections and deliveries. While accepting there is a role for large dispensaries Keen isn’t enthusiastic, painting a picture of the pharmacist as central part of local community, dispensing drugs in a responsible fashion. “A dispensing hub won’t be able to replace this,” he adds.

CCG view
The CCGs we spoke to were keen to point out that they do not commission community pharmacy, with many refusing to comment on the DH’s plans. Behind the scenes though according to Keen, there is concern among commissioners.
“CCGs are definitely interested in the changes,” he adds. In the Kent area Keen and other pharmacy colleagues work closely with the local CCG and local medical committe. “Pharmacy is a key part of their holistic approach for managing healthcare for their whole population.”
Julie Wood, chief executive of NHS Clinical Commissioners, agrees. “CCGs are desperate to shift investment out of hospital care and in to primary care settings,” she states, believing that partners in the system need to work together. While diplomatic in her response to the proposals, Wood is clear that the cuts – if they do come – shouldn’t negatively affect patients. “It is important that patient access where it is needed, is not compromised in any re-shaping of the contractual framework for community pharmacy.”
One of the reasons CCGs are likely to be concerned by the cuts is because of the increasing role that pharmacy is playing in population health strategies. A passionate advocate for the strength of the sector is Rena Amin a pharmacist who also works as a joint associate director medicine management for Greenwich CCG.
“As a commissioner all the clinical stakeholders are equally important in improving outcomes for the NHS,” she states confidently. Amin has been instrumental in improving communication between the CCG and pharmacy, and is working on a number of new projects to strengthen relationships and increasingly move services to pharmacies.
Amin is keen to explore how CCGs can use pharmacy, and it is clear to her that increased responsibilites will need to come with increased funding. “If we are asking community pharmacists to step up to a more clinical role we will need payment for this.”
In fact, co-commissioning may offer a number of new opportunities for pharmacy to provide new services, accessing the funding that comes with it. The problem is, according to Sharpe, they may not have the capacity to do so locally. “Faced with funding cuts the only option for pharmacies will be to reduce staffing levels, opening hours or voluntary support services,” she cautions.
Perhaps the biggest concern for CCGs, as Ridge, Gidley and Keen all agree, is that any reduction in capacity in community pharmacy could lead to an increase in appointments for GPs and potentially increased pressure on A&E departments. The reason is that they have concentrated on numbers, and not systems. “There is no sign of a plan, which is frustrating,” says Gidley.
The problem is, the sector feels that there clearly is untapped potential in the sector. Sue Sharpe, PSNC chief executive, adds: “There is so much more that community pharmacy could and would like to do to support local communities.” Asked to explain what areas pharmacy can help, she continues: “From treating minor conditions or offering NHS emergency supplies of medicines, to providing more structured support to help people to manage their long-term conditions.”

Integration fund
The DH and NHS England talk of a sector that needs to change. One way they hope to achieve this is through their recently announced integration fund. The DH has set aside £31 million for a pilot project to fund 403 new clinical pharmacist posts across 73 sites, covering 698 practices in England, supporting over 7 million patients.
This chance to shine is embraced by pharmacy, with Gidley adding: “It’s an opportunity to show what pharmacies can do”. The problem is, Sharpe points out in an open letter to Dr Ridge on behalf of PSNC, that the money is not specifically for community pharmacy.
While not dismissing the opportunity, Gidley has concerns that the money is unconnected to the changes to community pharmacy, describing it as “small and finite”. She also cautions that the money will also have to cover infrastructure and integration costs, which means it will take time for patients to feel the benefit of these changes.
 “If there is new money and new investment, some of that money should be spent on clinical pharmacists spent in practices,” believes Mark Spencer, NHS Alliance co-chair. “I can’t see many CCGs being flush with GPs. Community pharmacists could be one solution.”
Pointing out that the cuts are yet to be finalised, Spencer and the Alliance are optimistic about the opportunities for pharmacists. The problem comes down to money. As a GP partner, McGilligan, welcomes the idea of a pharmacist in his practice, but questions the finances. The problem, says McGilligan, is that the pharmacist would be employed by the practice, but it won’t feel the benefits. “We can’t justify this to save money for the CCG.”

The need to change
It’s widely accepted that the NHS needs to become more efficient to deal with the challenges it faces. Sharpe acknowledges that the pharmacy sector can’t be immune from playing its part. The problem is that these cuts seem, to most involved, to be arbitrary.
Naturally, lobby groups and professional organisations will be against any proposed cuts – they wouldn’t be doing their job if they weren’t. What is less understood is the impact that these cuts will have. For Wood, any cuts mustn’t affect the concept of a whole system approach to health. “We must have a system that is not fragmented and supports better clinical integration across general practice and community pharmacy.”
Pharmacists have said that the short time frame will leave them with no choice but to cut staff, which is likely to have an immediate effect on demand. Cautioning against immediate cuts, Sharpe offers her view: “We can see no sense in taking measures that will save relatively small sums but will drive great increases in demand for other more costly health services.”
“There is a risk of destabilising the current situation,” adds Spencer. “I think arbitrary cuts and widespread closures of pharmacists would be a bad thing,” pointing out how this view is likely to be shared across the health community.
The immediate impact of the proposed cuts is difficult to quantify. It’s much easier to assess the PR impact, with recent proposed closures in Falmouth, Cambridge and Rugby making headlines recently. A petition launched by the National Pharmacy Association has already reached 500,000 signatures. The Support Your Local Pharmacy campaign shows no signs of slowing down, with MPs becoming involved and questions asked in the House of Commons.
As leaders of local healthcare, it’s a conversation that CCGs are likely to be drawn in to. “CCGs will be in the firing line,” cautions McGilligan, describing a situation where when local health services are affected, it’s local health leaders that often take the blame.
With the junior doctors’ strike ongoing and other issues boiling under the surface, the DH and NHS England look likely to be drawn into another public confrontation with a well-established and popular health bodies. It’s clear that everyone wants to transform community pharmacy, it’s just that nobody can agree how best to do it.

Lawrie Jones, freelance health reporter.

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