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The community pharmacy conundrum

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I HAVE a shocking confession, so you’d better prepare yourself and perhaps even sit down. Ready? Ok, deep breath, here we go: there are times when I don’t think community pharmacy will survive. There, I’ve said it.


Well the future of pharmacy isn’t in the hands of pharmacists. The current network of community pharmacies and the majority of services they provide are governed by the national contract, the national contract is negotiated between the NHS and pharmacy owners, yet the majority of community pharmacists (65 percent) are employees, so while it’s individual pharmacist who can make a difference, for the most part they are stuck in a rigid system that doesn’t allow them any flexibility in the services they offer because of the many constraints upon their daily practice. The two main constraints are time and money.

Contractor woes

Now I’m not suggesting contractors are the bad guys of the piece (I used to be one after all) far from it, they are simply victims of an archaic remuneration system that has failed to keep pace with the ambitions of pharmacy, the necessity of the NHS to get value for money (better patient outcomes) and the healthcare needs of patients. And now they are caught in a precarious position where the supply function and associated profit is an integral component of the current contract and it is this which is retarding the development of pharmacy practice, thereby jeopardising the future of pharmacy as the dispensing role continues to occupy the majority of our time.

Community pharmacy operates in a monopsony (Wikipedia is your friend here): we have only one main customer — the NHS, and this one customer is responsible for contributing around 90 percent of the average pharmacy’s turnover. As a business model this is less than ideal.

So what is the problem? Well, in order to deliver value for money for the NHS and secure the future of the profession we need to provide pharmaceutical care from community pharmacies. This is not a choice, but a financial imperative for the NHS. I don’t mean the occasional medication review here and there or piecemeal work and fighting for scraps of money, I mean a whole-hearted full commitment to spending the majority of time with patients to improve health outcomes.

The issue though is, that despite what employee pharmacists might think, pharmacy owners don’t go home at night pour themselves a glass of champagne and count wads of money (it’s not the 80s), pharmacy income is being progressively squeezed making things very tight. While the global sum usually increases annually and these figures seem huge – £2 billion in England – when you take into account the annual prescription volume increase as well as inflation then it leaves little room for manoeuvre. And then there’s rising rent and rates, utility bills, IT fees, insurance costs and of course staff who expect wage increases.

Is it any wonder then that contractors are reluctant to take on new roles without additional money becoming available? Some argue that providing some free services will show goodwill and payment might follow. A nice idea (try pitching that on Dragon’s Den), but if we don’t value our services by putting a price on them who will? We’ve been providing a host of free services for decades so much so that we no longer even expect payment for them. Does the saga of monitored dosage systems ring any bells? Always sure to elicit a groan from weary pharmacists, they are the scourge of the profession. Let’s not fall into that trap again.

So how do we square all this with the ambitions of pharmacists and documents like Prescription for Excellence and what do grassroots pharmacists think and how can they influence what is happening? We already know what pharmacy leaders, pharmacy politicians and the NHS think. Is it time that employee pharmacists had an influence on the future of community pharmacy instead of being swept along by the wave of developments over which they have no control? It’s a difficult one, as contractors have invested heavily in their businesses and would like to avoid any scenario that is inadvertently detrimental to the current remuneration arrangements.

Future perfect

The question I think we need to address is: if we had a blank sheet of paper, would we invent community pharmacy in its existing format? No. Well, I wouldn’t.

If I were to redesign community pharmacy services I’d keep the existing network of pharmacies with minor readjustments (accessibility is impressive), delegate as much of the dispensing process as possible, ideally using automated dispensing robots (or outsource it) and provide a whole range of pharmaceutical services using the knowledge and skills of pharmacists to help those with long term medical conditions, ensuring of course that funding for the future was secured.

I’d also make available a useful range of pharmacy medicines as opposed to the current extensive range of products of dubious efficacy (it’s time we addressed this), allow electronic access to patient cares summaries and ensure all pharmacists were able to prescribe when appropriate. I’d also encourage other healthcare professionals to spend time in a pharmacy to see what we do day-to-day. This could be an effective way of encouraging inter-professional working, that doesn’t happen often enough in community pharmacy but could contribute to embedding community pharmacy as a part of the wider healthcare team.

Another threat to pharmacy comes from other colleagues: primary care pharmacists. If we don’t step up and provide pharmaceutical care services from pharmacies there is a real danger that primary care pharmacists will take all these roles away from community pharmacy and we will be left clinging on tightly to the dispensing role (fiercely protecting it from ACTs). If that happens the NHS is likely to seek cheaper alternatives and then community pharmacy as we know it is doomed.

But the good news is that enthusiasm is contagious and if the attendance at RPS local practice forums, pharmacy conferences, seminar and conventions and of course the continual updates and information from the pharmacy twitterati (you know who you are) is anything to go by then the desire to improve community pharmacy is there. We just need to turn it into reality, prove our worth, get involved and support pharmacy organisations that promote our profession.

Renowned futurist and inventor Buckminster Fuller has some useful advice: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.”

The success of community pharmacy is dependent on a new model of practice, we need to make changes now and all pharmacists should be part of that process. As Tony Blair once said: “You’re the future, now make the most of it.”

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