Community pharmacy cuts: a breakdown of a flawed rationale

On 17 December 2015, the Department of Health (DH) released a plan to cut funding for community pharmacy by 6% in 2016 and introduce several concepts that it claims will make community pharmacy in England more cost efficient. The letter from Keith Ridge, England’s chief pharmaceutical officer, and Will Cavendish, the DH’s director general of innovation calls for community pharmacy to be at the heart of the NHS while at the same time announcing a disinvestment. Most worrying of all, the letter implies that pharmacy is merely a distribution channel for medicines, rather than being a valuable asset in health and social care that supports patients at the heart of the community.

If the cuts go ahead, patients and the public will suffer.

Already efficient

While the letter suggests that community pharmacy needs to be more efficient, it does not acknowledge that the sector has already delivered 4% year-on-year efficiency savings^[1]
. Community pharmacy is already one of the most efficient sectors in the NHS. There is still no impact assessment to explain the thinking behind the £170m (6% of total budget) cut. The cost of medicines and supply are lower in the UK than nearly any other major market in Europe, the United States or Canada. Efficient and competitive procurement of medicines within community pharmacy has saved the taxpayer more than £10bn in the past ten years^[2]
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Measuring accessibility

It appears that the architects of the plan are receptive to the idea of many community pharmacies closing. Alistair Burt, minister for community and social care with responsibility for pharmacy, spoke to the All-Party Pharmacy Group on 13 January 2016 and acknowledged that between 1,000 and 3,000 pharmacies could close^[3]
as a result of the cuts. The case for reducing the size of the network seems to be based on a superficial argument that there are too many pharmacies in some parts of the country because “40% of pharmacies are in a cluster where there are three or more pharmacies within ten minutes’ walk”.

A distance that may appear to be a ten-minute walk for a healthy young adult may take much longer for an elderly person with mobility problems or a parent with young children. There has been no consideration of the fact that pharmacies often cater to specialist needs of their communities (for example, by employing staff who speak languages popular in the locality) and that this diversity could be lost if pharmacies close. There is also a capacity issue. Squeezing the work of two pharmacies into one premises could lead to a busy, inefficient and unsafe single operation.

The argument that we have too many community pharmacies in England does not stand up to scrutiny with international comparisons

The argument that we have too many community pharmacies in England does not stand up to scrutiny with international comparisons. The number of pharmacies in Britain per head is in line with the United States, and is much lower than France, Germany, Italy and Spain^[4]
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Automated dispensing

In the letter announcing the cuts, its authors argue that large-scale automated dispensing, such as hub-and-spoke arrangements, provides opportunities for efficiencies. They claim that “this could help pharmacies lower their operating costs and free pharmacists to provide more clinical services and public health services”. The National Pharmacy Association (NPA) recently held a task-and-finish group to investigate inter-company hub-and-spoke arrangements – in these arrangements both the hub and the spoke are registered pharmacies, where the hub assembles the medicine and the spoke pharmacy makes and takes final responsibility for the supply. We interviewed experts in the field from the UK and Europe and commissioned a review of the literature on these arrangements. Although we found that there may be the potential for off-site assembly to release some capacity within pharmacies, we found no evidence that operating costs would be reduced. Transferring the assembly of medicines off-site only works when the staff time released is deployed to additional face-to-face services. Even then, there may be other procurement costs, particularly if this model were to lead to less competition among suppliers, which could result in inter-company hub-and-spoke adding costs to the taxpayer. There are also legal and practice issues that go beyond the UK government’s current plans to amend medicines legislation that need to be resolved before inter-company hub-and-spoke arrangements can even be considered.

Home delivery: not new

One initiative that the government has suggested as a cost-saving measure is home delivery of prescriptions. It is implied that this would be an innovation, but most community pharmacies already offer a home delivery service – something that they currently do without NHS support. Many of the people who benefit from this service are housebound. This is just one of the many unseen, but highly valuable, services that pharmacies provide to their communities.

If home delivery were to become part of the NHS offering, it would need additional funding, paid for by the taxpayer

Yet home delivery is expensive, more so for medicines than ordinary items of commerce because of the need to maintain a cold chain for certain medicines and deal with the legal requirements of controlled drugs. This appears to be another element unaccounted for within the proposal. If home delivery were to become part of the NHS offering, it would need additional funding, paid for by the taxpayer.

Click-and-collect: already available

The plan proposes the introduction of prescription ‘click-and-collect’ services, its authors apparently unaware that the vast majority of pharmacies already offer convenient repeat prescription services. Most patients engage with repeat prescription services face-to-face or via the telephone, and some pharmacies have already developed online ordering facilities. Community pharmacy is a competitive and customer-focused sector, which responds to patient demand. The real problem is the low uptake of the repeat dispensing service by GP surgeries — something that is not within the control of pharmacy.

Social function on the high street

The letter is also oblivious to the social capital embedded within the community pharmacy network. Community pharmacies fulfil a social function by providing a space for individuals to develop networks of trust and social support. For example, for many older people who live alone, a visit to a pharmacy constitutes valued social interaction^[5]
. Secure health infrastructure is important to maintain resilient communities. Community pharmacies have made a commitment to their local community by virtue of their financial investment and present a sustainable asset. A pharmacy is one of the core businesses that can make a difference between a viable high street and one that fails commercially because, if people can service all their immediate needs — banking, comestible, retail, medical — on one high street, they will be more inclined to do their shopping there.

Where is the logic in driving the most accessible healthcare professional to be less available to the public?

A typical community pharmacy is open for over 50 hours per week, much more than the NHS contractual requirement of 40 hours. Pharmacy owners will need to consider whether they cut staff and reduce opening hours in response to new business constraints. At a time when health secretary Jeremy Hunt is trying to introduce a seven-day NHS, where is the logic in driving the most accessible healthcare professional to be less available to the public?

Conjecture, not evidence

This jumble of proposals from the DH is based on conjecture not evidence, and is not grounded in front-line reality. Given the right support from government, community pharmacy could do so much more to help deliver NHS England’s ‘Five year forward view’, which sets out a strategy for the NHS based around the new models of care^[6]
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Community pharmacy in England has asked for a minor ailments scheme, better integration between pharmacy and NHS 111, new pharmacy services for patients with long-term conditions and enhanced prescribing rights for pharmacists. The case for a greater role for pharmacy in the prevention of ill health has also been made. With a shortage of doctors and nurses, the government should be investing in pharmacy to help solve the NHS crisis, not worsen it through funding cuts.

The DH needs to pause and rethink its plan before it does irreversible damage to the community pharmacy network and diminishes the potential for pharmacy to make a greater contribution to the health and well-being of patients across the country.