The UK Government's austerity eye has turned on community pharmacy, with ministers demanding funding cuts and improvements in service, but England's 11,000 pharmacies are fighting back
A week before Christmas last year, pharmacy ministerAlistair Burt sent a letter to the Pharmaceutical Services Negotiating Committee (PSNC) – the official representative body for community pharmacy – outlining 'changes to the community pharmacy contractual framework for 2016/17 and beyond'. This letter – also signed by the director general for Innovation, Growth and Technology at the Department of Health (DH) and the Chief Pharmaceutical Officer – prompted outrage among England's 50,000 registered pharmacists.
In effect, the letter announced a six percent cut to community pharmacy funding for 2016/17, reducing the total from £2.8bn to £2.63bn. It said: 'The Government believes those efficiencies can be made within community pharmacy without comprising the quality of services or public access to them.' The minister added that there were too many pharmacies in some areas and that 'large-scale automated dispensing' could help with efficiencies.
Pharmacy leaders were quick to criticise the move. Speaking at Sigma Pharmaceuticals' 8th annual conference in Ocho Rios in Jamaica, Sue Sharpe, chief executive of PNSC, described the plans as "ill-conceived, ill-thought-out" and "profoundly stupid".
For Claire Ward, chair of Pharmacy Voice – the 'stronger, unified voice' of community pharmacy – the government's ideas are just that. "The suggestions in that letter – I won't call them proposals – have no evidence base behind them and make huge assumptions about how community pharmacy currently operates," she says. "[The letter] doesn't recognise that change has already taken place. It suggests sudden and arbitrary cuts in funding that are absolutely inconsistent with what the government says it wants to achieve – a service that is responsive to patient need and delivers better patient outcomes. This consultation won't do that; it will undermine it."
While the minister's letter made clear that funding cuts were unavoidable, it also announced a consultation process. "There has not been a proper consultation by any means," says Ian Strachan, chairman of the National Pharmacy Association. "A consultation process is about sharing information, it is about understanding the scope of what they're trying to do. Yet this feels more like an imposition, more like an ideology. It almost feels like a prejudice, a grudge against the contractor model and premises-based framework.
"The government thought there was a lot more money swimming around in community pharmacy than there actually is. This all goes to show that there is a lack of understanding about this sector. This is not going to be the walk in the park that the government imagined it to be." Perhaps in a sign that the government is listening, Burt announced that the consultation period would be extended to 24 May to give more time for the government to develop its proposals in partnership with stakeholders.
Community pharmacy is hardly alone in receiving cuts to its public funding, but what impact would the government's plans have on the health of the nation?
For the Local Government Association, the greatest risk is for pharmacies to close. "Maintaining community pharmacies is crucial to keeping older and frail people independent," says Izzi Seccombe, LGA community wellbeing spokeswoman. "They need to be at the heart of communities, close to where people shop, work and go about their daily lives, rather than the heart of the NHS."
Calling for additional investment, Seccombe stresses: "Being at the heart of communities means pharmacies see people in every state of health and are ideally placed to play a central role in the prevention of illness, which can reduce costs and pressures on the NHS and social care."
For Claire Ward, the risks are system-wide. "We have a high-quality system for delivering healthcare services. We have a supply chain that is hugely efficient and is driving down the costs of medicine delivery year on year. A community pharmacy employs six to eight members of staff on average, which is an important contribution in a local community. Every day, pharmacy drivers go out to deliver medicines to patients but they also check whether they are ok, make sure their carers are coming in to help them, and we do not even get paid for this service. All of these are at risk."
Ward adds: "Also at risk is the future potential of community pharmacy to deliver great value, safe and effective new solutions that will reduce the demand on GP and urgent care services, which is what the government says it wants to achieve."
On one message, pharmacy leaders stand shoulder to shoulder – pharmacy needs to change. "We have a network that can do more and wants to do more – transformation is not the problem," says the NPA's Strachan. "If you want transformation then talk to us, work with us to develop the change from within. Don't create ideas among bureaucrats and civil servants who don't understand how the sector works."
Pharmacy veteran and Fellow of the Royal Pharmaceutical Society, Mike Smith, is quick to warn pharmacists that change must happen quickly. "The first cut is the deepest but it has to be the only one. We must prove to the DH that we're worth it. This is about survival; the NHS has changed both locally and nationally and we've been guilty of complacency. We have to change and work with the DH to reduce the unbelievable amount of waste in the NHS and overcome the burden of administration. We have to sharpen up our act as these cuts are going to hit hard."
A way forward?
Focusing on the customer is a simple and easy way for pharmacies to work out how best to change, says Smith. "The relationship between the pharmacist and patient is sacrosanct and anything that undermines that undermines our profession, but we also have to optimise our transactional value – data suggests that 78 percent of people who come into the pharmacy don't buy anything. We need to maximise our footfall, shout about what we do and focus on quality, be the very best at what we do, and that starts by understanding our customer's needs."
He quotes Bill Gates: "He said that your most unhappy customers are your greatest source of learning and we should apply that to both our customers and healthcare providers. We have to start thinking outside the box, be proactive, be strategic."
The best way forward for pharmacy to change is for it to be fully integrated into the NHS, says Pharmacy Voice's Ward. "We need an approach to change that starts with a shared vision of the future for community pharmacy as a fully integrated part of the NHS. We cannot be expected to deliver at a level of the NHS if it's not part of the NHS. We need to establish meaningful partnerships with healthcare providers… to manage a clear and funded plan for integrating community pharmacy into the NHS 111 service, so that we can direct patients to pharmacies rather than hitting A&E's front doors. Most important, the jewel in the crown, we need a national service for minor ailments. These will deliver the outcomes the government says they want."