The King’s Fund and the Nuffield Trust were commissioned by Community Pharmacy England (CPE) to develop a vision for community pharmacy that would support CPE in its leadership role, underpin a strategy for the sector and suggest how the vision might be implemented. That vision was published in September 2023 after almost a year of stakeholder engagement, consultation and research.
Given that responsibility for commissioning NHS community pharmacy transferred to ICBs from April 2023, with the aim of supporting the development of services that are responsive to local needs, it is maybe not surprising that the implementation of the vision will require significant action from ICSs, both integrated care boards and integrated care partnerships. This is not without its challenges, not least capacity and readiness within ICSs to do this work.
What is the vision that ICSs will need to think about?
The ambition for community pharmacy, and indeed the wider pharmacy sector, to take on more direct clinical work with patients is clear. From 2026, all pharmacists will qualify as independent prescribers, and will have enhanced clinical, population health and consultation skills. The delivery plan for recovering access to primary care published by NHS England in May 2023 includes a commitment to invest up to £645 million to expand community pharmacy services to provide more direct patient care.
In addition to providing more direct clinical work with patients, community pharmacies will also need to remain thriving businesses, continue to be a core part of the medicines supply chain, and work more closely with the wider health system. As well as accessing medicines, people will also be able to get clinical care for and services to prevent ill health. Community pharmacies will play a particularly important role in supporting people to self-care and helping their local populations to stay healthy and well, and a large proportion of patients with self-limiting conditions will use community pharmacy as their first contact point for treatment and advice.
The services offered by community pharmacy should be integrated with other parts of the health and care system, particularly other parts of primary care, so that patients can be quickly directed to the right part of the system. They should be able to offer attractive careers with opportunities for training and development for pharmacists, pharmacy technicians and other support roles. Pharmacists need to be valued members of multidisciplinary primary care teams, working with others to improve the health of their local populations.
Community pharmacy will make a significant and valued contribution to the goals of the wider health and care system, including the ambitions of the ICS.
So how can that vision be implemented and what do ICSs need to do?
From the starting point in 2023, there is clearly huge variation within the sector in terms of capacity and capability. We’ve suggested an approach to implementation that takes current variation into account, with a consistent national offer that is understandable to the public and may also avoid the frustration of people and patients not being able to access the service they expect. Our framework also allows for those pharmacies with greater capacity to move further, faster.
Our vision for realising the potential of community pharmacy is published at a time of unprecedented challenge for the health and care system in England. However, the range of issues affecting implementation are not new. The Community Pharmacy Clinical Services Review, published in 2016, found that despite the case for change being well made, at least among policy-makers, there were significant barriers that were hampering implementation.
Seven years on these issues are still very much present, including insufficient resource across primary care as a whole, with new models of care relying on shifting resource from one part of primary care to another, rather than overall investment.
The finance and contracting arrangements for primary care often inhibit new models of pharmacy, with complex funding flows, atomised commissioning and fragmented contracts that are hard to manage. And there is not enough capacity and capability within community pharmacy or within ICBs to oversee the type of transformation that is needed.
But there are things ICSs could do now to start to make progress on making this vison a reality.
The first is making sure there is clear leadership and a voice for community pharmacy; the ICB chief pharmacist role should provide clear clinical leadership for pharmacy across the ICB and lead the creation of strong local networks to support streamlined representation of the sector within ICSs.
It’s important for community pharmacy leaders to take on roles within cross system bodies like integrated care boards and primary care networks, but this engagement in system working and leadership needs to be funded, so we have recommended changes in the contract to reflect this to support community pharmacists have the capacity to develop leadership skills and work on shared issues with other professionals.
ICBs will need to deepen their skills and capacity to lead commissioning of community pharmacy, including a better understanding of how they will oversee the local market for community pharmacy, including entry and exit where that’s needed. As new services are designed and commissioned, leaders will need to take a co-production approach, working closely with local VCSE organisations, to ensure ongoing engagement with local communities.
The community pharmacy workforce needs to become firmly embedded in local ICS workforce strategies. We recommend that ICSs establish a pharmacy workforce board to consider the workforce issues as a whole, including pharmacist roles in hospitals, the community and general practice. ICSs will need to work closely with community pharmacy to ensure that commissioned services support their ambitions around workforce. This will include making sure the system is geared up to manage the cohort of pharmacists who will qualify as independent prescribers from 2026 onwards, but also upskilling the existing workforce.
Finally, just as in general practice, there will need to be changes to infrastructure and estate and we recommend that ICB estates planning takes community pharmacy into account when it is planning how to make best use of wider public estate in service delivery.
None of this is easy. And it will need money. But the alternative of underinvesting in primary care, means that long term goals around population health, and indeed short-term goals around improving access, can’t be met.
The biggest criticism we had from community pharmacy stakeholders when we were drafting this report is that the vision wasn’t bold enough. We know there are community pharmacies already raring to go further and faster. But we think this vision provides the balance of challenge and realism, so that the sector as a whole can move forward in a way that makes sense to the public and the wider health and care system and sets the tone for further development of community pharmacy.