Four ways to build a community pharmacy workforce fit for the future

The best ideas come from the ground up — but how do you turn those ideas into tangible change? You’ve got to start somewhere, and in this instance it started with a couple of tweets.

It’s sad that it’s taken a pandemic to bring to light the flaws in the set up of Community Pcy, but it will be a travesty if ‘we’ don’t do something about it after this is all over. We all need to be thinking about the new normal post pandemic and then start pushing for it

— Reena Barai (@REENABARAI) April 29, 2020

Totally agree Reena, would love a virtual drink and chat about this sometime!!

— Harpreet Chana (@harpreetkchana) April 30, 2020

Something that might have taken a long time to organise (or may have never happened) in a pre-pandemic world took straight off. Within a week, we held a virtual roundtable of 22 grassroots community pharmacists — we shared our experiences and learnings from the COVID-19 pandemic, and discussed what needs to happen next for community pharmacy.

A big theme weaving its way through our conversation was the stagnating pharmacy workforce, and we identified four major ways we need to change to be fit for the future.

And here they are. But we can’t drive these much-needed changes within our sector on our own — national pharmacy organisations, let’s work together to make these changes happen.

1. Push prescribing as far as it’ll go

In 2016, a survey by the General Pharmaceutical Council (GPhC) reported that 27% of respondents found it either ‘difficult’ or ‘very difficult’ to find opportunities to prescribe^[1]
. Later, in March 2018, The Pharmaceutical Journal reported that “11% (6,188) of the [GPhC’s] 55,275 registrants are independent prescribers [IPs]”^[2]
; it went on to say that 17% of the IP respondents from its survey had never prescribed, while a further 16% of these IPs said they had not used their qualification more than once per month.

By October 2020, the proportion of IP pharmacists had reached just 18%, according to figures provided by the GPhC (data on file). There appears to have been little improvement here, and our virtual roundtable corroborated these findings. We heard how many IP pharmacists, having paid for and completed the lengthy training, see their skills go to waste because they are not being given opportunities to use them.

Our consensus was that the currently commissioned national services — medicines use reviews (MURs), the new medicines service (NMS), and the Community Pharmacist Consultation Service (CPCS) — are not fully utilising the clinical skills of community pharmacists. We feel this is partly owing to the limited scope of the services, but importantly to a lack of referrals; for instance, in June 2020, the Pharmaceutical Services Negotiating Committee reported that 332,000 CPCS referrals had been made since the scheme’s introduction in late October 2019^[3]
. This equates to just 30 referrals per pharmacy registered to provide the service — just over one referral per week. Does this really make the most of the clinical skills of community pharmacists? The roundtable didn’t think so.

Even the tweak to the service, in which referrals by GPs also flow into the CPCS, does not go far enough to use IP pharmacists’ skills because it will not allow them to prescribe for the patients referred to them. Frustratingly, the IPs must instead refer patients back to the GP, when, in some cases, the pharmacist could have handled the medication initiation or change themselves.

Frankly, we want to do more, and we can do more. But until community pharmacists are allowed to prescribe from a community pharmacy setting, our situation will not change. We need more prescribing rights.

2. Take control of chronic conditions

So how do we get community pharmacy prescribing going? One way is to learn from our pharmacist colleagues in Canada, and initiate an ‘Alberta style’ care plan service; this involves community-based IP pharmacists leading the management of many long-term conditions, such as hypertension, and making the most of their regular contact and relationships with their patients to do this^[4]
.

This type of service would include pharmacists organising treatment plans, conducting regular monitoring, and prescribing and deprescribing of medication. There has been a lot of talk about this type of service being introduced in the UK, but there has been little action. Still, we continue to be restricted by a volume-based funding model that cannot support this type of service easily.

Scottish colleagues at the virtual roundtable spoke positively about their experience with Scotland’s Chronic Medication Service, an initiative that sees community pharmacists provide medication reviews, care plans and serial prescriptions for patients who sign up to the service. However, for the rest of the UK, even this kind of service seems out of reach. There is no other service that really manages long-term conditions from a pharmacy setting in the same way.

Can we not learn from our colleagues in Scotland, and in Canada? What are the barriers to introducing a nationally commissioned service in England that allows community pharmacists to manage long-term conditions? The answers to these questions were not clear to the group. We need answers from the top.

3. Let them grow, or watch them leave

The lack of opportunities for pharmacists to stretch their clinical and professional muscles puts us at risk of losing them. The pharmacists on the roundtable were particularly worried about losing valuable and talented IP pharmacists to the general practice sector, where there are some interesting new avenues: in 2019, there were already more than 1,000 full-time equivalent GP pharmacists, and funding is available for up to 20,000 additional staff, including pharmacists^[5]
.

Another concern was anecdotal evidence of community pharmacists leaving the sector after completing development courses, such as leadership modules and clinical diplomas, because they felt there were no clear pathways or outlets for their skills in community pharmacy.

This cannot be allowed to continue. We need to support our colleagues to be the best they can be in the sector they’ve invested so much of themselves in.

We know we must play a part in easing pressure on GPs, but there’s a way we can do this — not through the transference of staff, but through better utilisation of pharmacists’ clinical and prescribing skills, and through making the most of their location at the heart of the community.

Community pharmacists want to be treated in the same way as their hospital pharmacy colleagues, who are able to make simple changes to prescribing, such as brand/strength and formulation. During the first wave of COVID-19, community pharmacists were afforded autonomy and our roundtable pharmacists want that autonomy to be extended and formalised; they want less focus on standard operating procedures, and more focus on routinely exercising their trustworthy professional judgement.

4. Change the working culture

Here, we’re pushing for more responsibility for community pharmacists, but these changes cannot come without a change in our working culture — we seem to be doing more work for less.

While dispensing volume remained stagnant from 2017 to 2019, it has increased by 18.8% since 2008/2009 and, since then, we have also had the introduction of MURs, the NMS, flu vaccinations, the CPCS and the Quality Payment Scheme^[6]
. Despite this, total funding was cut from £2.687bn to £2.592bn in 2016–2017, and we have had flat funding ever since (and now up until 2024).

It is no wonder that in December 2020, a survey by the Royal Pharmaceutical Society reported that “89% of [respondents] said that they were at ‘high’ or ‘very high’ risk of burnout because of exhaustion, and 62% felt they had no work–life balance. More than 50% said that they’ve had to reconsider their career and no longer spend enough time with family and friends”^[7]
.

Our roundtable group feels we need a cultural shift in how workload is currently distributed within the dispensary. Most pharmacies currently operate a ‘backwards approach’, with the most clinically trained member of the team stuck at the back of the dispensary, and members with the least training speaking to patients and giving advice at the counter.

We need to challenge this: we want to see the pharmacist interacting with patients and offering clinical advice for the majority of their working day. We can free up their time by expanding the role of pharmacy technicians, who will not just accuracy check, but also provide services such as vaccinations.

When we have automation and/or barcode scanning of prescription items in place, most accuracy checking can occur without a pharmacist. We are calling on leadership to fund the setup of these systems, which will revolutionise our workforce.

We can also address our burnout problems with training. All community pharmacists, as the clinical (and usually operational) leads of their pharmacy, should undergo formal leadership development training to help manage workload and mental wellbeing. At the moment, training provision varies greatly depending on the employer and, in fact, around half of pharmacists say they are never given protected learning time^[8]
. We want to see formal training — either as part of the undergraduate degree or on the job.

If we are going to achieve all of this, we need more leading community pharmacists. We have some individuals in leadership positions, but the sector is far from having a ‘pool’ of strong grassroots practitioners as leaders. We need formal leadership development to recognise and nurture emerging talent. Mentoring programmes are helpful, but without any formal progression, talented individuals and future leaders are being lost to other sectors.

Making this happen

The role of the community pharmacist needs to change. The division of workload needs to change. And there needs to be a clearer career progression pathway. This is evident. But these changes need to be properly coordinated and funded.

Our virtual roundtable was in absolute agreement that while all the current national bodies have their own priorities, they need to come together to agree a way forward for the community pharmacy workforce. Our current scattered approach to workforce development has no clear long-term strategic objectives. Perhaps we need a pan-organisational pharmacy workforce committee.

The time to act on this is now. Our professional bodies must collectively capitalise on the current spotlight on community pharmacy and its indispensability during the COVID-19 pandemic.

We have a golden opportunity here, and pharmacists on the ground came together one evening, in their own time, to let the sector know that they are ready and willing to make the best of it.