The CCA’s pharmacy paradox paper featured in the Health Service Journal. Read our paradox paper below:
The government’s planned £645 million investment in community pharmacies in England over the next two years has raised questions about how the sector can deliver more, amid repeated warnings of an ever-worsening workforce crisis.
Community pharmacies can and will deliver the government plans to improve access to primary care, if the NHS is ambitious with its commissioning, allows better use of skills, and embraces new and advanced technologies.
The NHS ‘Delivery Plan for Recovering Access to Primary Care’ announced a Pharmacy First service, focussing on seven minor health conditions initially. This service is a unique opportunity for pharmacies to free up GP capacity, improve primary care resilience and immediately enhance patient access.
However, pharmacies are under immense and growing pressure. Funding constraints have resulted in an annual shortfall of at least £67,000 per pharmacy in England.  This has led to 720 pharmacies permanently shutting their doors, which have been disproportionately skewed towards the most disadvantaged communities, with over 40% taking place in the 20% most deprived parts of England. 
At the same time, the sector is experiencing a workforce crisis, exacerbated by NHS recruitment of community pharmacists into primary care networks.  Pharmacies are also facing a significant increase in demand on services:
- Community pharmacies dispensed 1.075 billion items prescription items in 2022/2023, around 60 million (6%) more than in 2017/18. 
- During the same period, the number of “touchpoints” between pharmacists and patients through nationally commissioned clinical services increased by 80% from 5.7 million to around 10.2 million. 
A stretched and reduced pharmacy workforce is having to deliver more and more. This is unsustainable.
Community pharmacy offers a route to transforming patient access to care. This investment should be a starting point for huge patient benefits. Pharmacies could provide care to millions of patients, transferring 42 million appointments from general practice annually. 
In 2019, at the start of the five-year CPCF, the government committed to key legislative changes to create the efficiencies needed by community pharmacies.  Unfortunately, in the fourth year of the five-year contract, these have not yet materialised.
Unless the tension between ambition and capacity is addressed, there is a risk that community pharmacies will not only, not meet their potential, but the existing offer could be compromised.
To resolve the current paradox between ambition and reality, several reforms are needed:
- Ambitious commissioning: With the right funding, pharmacies can quickly scale up their operations to provide new care. This was seen during the Covid vaccination programme, and other pandemic services. To allow investment in people, training, and infrastructure, NHSE must commission ambitious, fully funded national services. For example, the recent announcement for a Pharmacy First service should not be limited to seven common conditions, but rapidly expanded to include all common conditions and Independent Prescribing. CCA analysis shows an ambitious Pharmacy First service in England could free up over 30 million GP appointments each year, rather than the 6 million we expect that the current government plans will free up.
- Better use of skills mix: Whilst the time spent delivering clinical services is growing, pharmacists still spend most of their time dispensing. To increase capacity and improve access to clinical care, parts of the existing workload must be redistributed among the pharmacy team enabled through key legislative change. Changes to pharmacy supervision would allow this, but as yet there have been no changes to this foundational legislation.
- Better use of new and advanced technologies: Better use of technology could vastly increase capacity by moving workload away from pharmacy teams. Whilst many businesses have already invested significant funds into automation, further investment relies on the commissioning of services in physical “bricks and mortar” pharmacies. Without clarity on future funded opportunities, businesses will struggle to justify more investment. Yet again promised legislation to maximise these opportunities, such as changes to Hub and Spoke requirements, and Original Pack Dispensing, have not yet materialised.
Malcolm Harrison, Chief Executive of the CCA said:
“Patient demand on pharmacies has increased drastically in the last few years. We know the sector has the potential to do more, but without immediate investment it is quickly reaching breaking point.
The government committed to legislative action four years ago and these changes are yet to materialise. Without these changes and immediate investment, the true potential of the sector will never truly be realised.
It is not just the implementation of Pharmacy First at risk, other existing and essential services that could also grind to a halt”.
NOTES TO EDITOR
- The Company Chemists’ Association (CCA) is the trade association for large pharmacy operators across Great Britain. Our members are Asda, Boots, LloydsPharmacy, Morrisons, Rowlands, Superdrug, Tesco and Well, who between them own and operate around 5,500 pharmacies, almost half the market.
- The ‘Delivery plan for recovering access to primary care’, published on 9th May 2023, outlined plans to commission a Pharmacy First service in England. The service which will cover 7 common conditions (Sinusitis, Sore Throat, Earache, Infected Insect Bite, Impetigo, Shingles and uncomplicated UTIs) is expected to launch before the end of 2023.
- Supervision’ is the term used in regulation 220 of the Human Medicines Regulations 2012 which says that a person must not sell a medicinal product unless that person is a pharmacist, or acts under the supervision of, a pharmacist. There are many interpretations of what this means in practice.
- As part of the 2019 CPCF the government committed to:
- pursue legislative change to allow all pharmacies to benefit from more efficient hub and spoke dispensing, enabling increased use of automation and all the benefits that that brings.
- explore and implement greater use of original pack dispensing to support efficient automation.
- In the current ‘5-year deal’ with the community pharmacy sector, DHSC and NHS England agreed to several changes to allow greater efficiency for pharmacies dispensing. This included legislative changes such as changes to ‘supervision’, original pack dispensing, and Hub and Spoke across legal entities.
-  CCA, Funding gap in England equates to more than £67,000 per pharmacy, January 2023
- CCA, 40%+ of Pharmacy closures in last 7 years have occurred in the 20% most deprived parts of England, October 2022
-  CCA, NHS recruitment of pharmacists set to wipe out eight years’ worth of growth of the pharmacist workforce in England, May 2023
-  Dispensing data between April 2017 and February 2023 can be accessed here: NHS BSA, Pharmacy and appliance contractor dispensing data. At the time of writing March 2023 was not yet available and is based on estimates.
-  For the purpose of this paper, “patient touchpoint” is defined as an occasion where there is a pharmacist-patient interaction. The following data sources were used to estimate the number of touchpoints associated with national clinical services, between 2017/2018 and 2022/2023.
- New Medicine Service, Medicine Use Review, Appliance Use Review, Stoma Customisation, Community Pharmacy Consultation Service, Hepatitis C testing, Blood Pressure Checks, Ambulatory Blood Pressure Monitoring, Smoking Cessation consultations: NHS BSA, Pharmacy and appliance contractor dispensing data, March 2017- February 2023. At the time of writing data for March 2023 was not yet available and is based on estimates.
- Discharge Medicine Service: NHS BSA, Discharge Medicine Service, March 2021- February 2023. At the time of writing data for March 2023 was not yet available and is based on estimates.
- Flu vaccines: PSNC, Flu Vaccination – Statistics, September 2017- March 2023
-  CCA, CCA Prospectus – A future for community pharmacy, February 2023
-  NHSE/DHSC, Community Pharmacy Contractual Framework: 2019 to 2024, July 2019
-  CCA, CCA Prospectus – A future for community pharmacy, February 2023