To put the present state of community pharmacy into context we need to go back in time a bit.
Before 2005, owning a pharmacy was basically a licence to print money. It was virtually impossible not to be profitable.
But then a new contractual framework for community pharmacies was introduced in April 2005. The basis for the new contract meant that pharmacies would receive less money for the medicines that they dispensed and would be invited to provide additional services to earn back the money lost.
Let’s break this down.
The first part was called Category M, which is used to set the reimbursement prices of over 500 medicines. This means that pharmacies receive a set price from the government for a drug given out regardless of the price the pharmacy actually paid. It’s supposed to ensure a profit margin for pharmacy, but as the price is lowered at regular intervals it has had a huge impact on pharmacy base line profitability.
The funding cuts just kept coming.
On October 20, 2016 the Government imposed a two-year funding package on community pharmacy, with a £113 million reduction in funding in for 2016/17. This took total funding to £2.687 billion for 2016/17. This was a reduction of 4% compared with 2015/16, and meant that pharmacies saw their funding for December 2016 to March 2017 fall by an average of 12% compared with November 2016 levels.
This was followed by a reduction in 2017/18 to £2.592 billion for the financial year, which saw funding levels from April 2017 drop by around 7.5% compared with November 2016 levels .
In order to compensate for these cuts, pharmacists were encouraged to take on extra services, these were broken down into four categories:
- Essential — every pharmacy must offer these services.
- Advanced and enhanced serves — optional services including the controversial Medicine Use Review (MUR).
- Locally commissioned services — these depend on what is needed locally. I live in rural west Wales and as such we have many holiday makers. The local health board set up a triage and treat scheme so that if someone was injured they could go to the pharmacy and get treated instead of A&E. This was designed to take the pressure off the busy A&E departments.
These new services are very valuable for patients. I have saved lives through MURs and Discharge Medicine Use review (DMRs). I have helped dozens of people quit smoking, lose weight and literally glued people back together (under the triage and treat scheme). This has saved the NHS masses of money in fewer A&E admissions, fewer GP appointments and rehospitalisation.
The 2005 contract changed everything.
Pharmacy went from being very profitable businesses, at the expense of the NHS, to ones where the margins are now so tight that it is very difficult to make a profit. All pharmacies in the UK are run by private businesses. Many of these are organisations are huge multinationals, and as such they are run to a capitalist model to make profit for shareholders. This is their true function, and rightly so. A business must be profitable if it is to survive.
So how can these companies retain some form of profitability? They employ the usual streamlining tactics. For example reducing staffing levels, using zero hours contracts and ensuring that the pharmacy is as efficient as possible.
But, they have one trick up their sleeve to use that would not be available in other models: they have the advanced and enhanced services. The area and store managers encourage their pharmacists to complete as many of these as they can per week. This explains the controversy of the MUR. These are worth £28 per consultation to that pharmacy and activity is capped at 400 per year. This means an added profit of £11,200 for no extra cost to the company.
The managers ask us to do as many as possible. Different managers use different levels of persuasion, from polite requests, to outright threatening dismissal if targets are not achieved. It is after all the manager’s job to ensure profitability.
Coming back to the enhanced services, while they are valuable, they do take time and with the staffing levels reduced to reflect the cuts in funding, pressure inevitably falls onto the pharmacist.
How do we find the time to do all of these extra services alongside the regular job of dispensing medication? This is especially difficult when the number of prescriptions dispensed increases by about 2% a year, year-on-year.
Where do I draw the line and say that we do not have enough staff, I cannot open the shop as it will not be safe? I have a professional obligation to do this if I feel that lack of staff might lead to patient harm, but then keeping the shop closed means that customers cannot collect their medication.
How is that putting the customer first? If I go for a break, customers cannot collect their medication (as medication cannot be sold or handed out unless that pharmacist is in charge), but if I don’t then I am not taking a break and might be at an increased risk of making a mistake. Which is the lesser of the two evils?
If I feel unwell, say I have a minor cold, I would generally be thought of as well enough to go to work. But what then if I make a mistake because of that illness? I would be causing patient harm. So, every time I’m even slightly ill, I have a very difficult decision to make. Call in sick and risk the pharmacy not being able to open as they cannot find a pharmacist to replace me, or go into work and possibly make a mistake?
The system is inherently flawed and profit driven.
As a professional pharmacist my regulatory body says that my number one priority should be the patient, and rightly so. Yet as a manager it is my duty to ensure that my shop is as profitable as possible. So how do I reconcile them both when I am a pharmacist store manager?
The reality is that I cannot.
As it says in the Bible Matthew 6:24 “No one can serve two masters. For you will hate one and love the other; you will be devoted to one and despise the other. You cannot serve both God and money.”
Every day I am expected to split my loyalty between being as profitable as I can for my employer, save the NHS as much money as possible, keeping the customer happy and healthy and at the heart of everything I do whilst protecting my professional and ethical status; all without losing my mind. It is an impossible task.
I feel that the only solution it to nationalise community pharmacies. This takes away the conflict of interest that every community pharmacist has to face on a daily basis.
Cerian Screen is a pharmacist based in Wales