Amid the warm words surrounding the rollout of NHS England’s Pharmacy First minor ailments service, one MP caveated his welcome with a concern about patient access to community pharmacy.

“I very much welcome this initiative to encourage our pharmacies to provide more frontline healthcare. People need to know about this, because they often do not think of going to the pharmacy,” said Bernard Jenkin, MP for Harwich and North Essex, in Parliament on 31 January 2024.

“What work are the government doing in larger population centres, such as Harwich and Dovercourt, which has over 20,000 people but no out-of-hours pharmacy cover?”

Health minister Andrea Leadsom reassured Jenkin that pharmacies are open “for up to 72 hours a week in most cases, and up to 100 hours in some cases, which means there is weekend accessibility”.

However, analysis by The Pharmaceutical Journal of quarterly NHS figures on the pharmaceutical list has revealed that this level of accessibility is diminishing.

Data published by NHS Business Services Authority (BSA) reveal that, out of 10,696 pharmacies that have remained open between December 2022 and December 2023 in England, 2,381 pharmacies (22%) had reduced their opening hours in that time.

Of the pharmacies that have reduced their hours over the past year, they have, on average, opened their doors for 10.5 fewer hours per week.

Community pharmacies in England are usually required to open for 40 core hours, unless they have a specific exemption from NHS England.

They can also open for ‘supplementary’ extra hours if they choose. NHS England regulations introduced in October 2022 state that pharmacies can increase their supplementary hours with no notice, but if they want to reduce them, they must give NHS England at least five weeks’ notice.

NHS England does not have to approve a cut in supplementary opening hours.

Decline in opening hours

The Pharmaceutical Journal’s analysis shows that while 22% of pharmacies in England are opening for an average of 10.5 fewer hours per week, there is a wide variation in the reduction in hours.

The most common drop in opening hours is between 2 and 4 hours each week — a change made by 490 pharmacies. Some 263 pharmacies have cut their opening hours by up to 2 hours each week, and 19 pharmacies are opening by more than 32 fewer hours each week (see Figure 1).

Leyla Hannbeck, chief executive of the Association of Independent Multiple Pharmacies, says the reason for shorter opening hours is “simply that pharmacy owners must reduce all operating costs by as much as possible or go bankrupt under the current funding regime”.

“Opening at times of the day when income does not cover opening costs used to be cross-funded by more profitable times of the day,” she says.

“Most managed pharmacies are now losing money so there are no funds for cross-funding anymore.”

A report commissioned by the National Pharmacy Association, published in September 2022, highlighted the funding crisis facing the community sector, warning of a “looming pharmacy collapse” as rising inflation, combined with static funding, means that community pharmacy remuneration “is already 25% below its 2015 level”.

The funding shortfall has been met, in part, with a government investment of £645m over the next two years, which will pay pharmacies to provide the NHS Pharmacy First common conditions service that launched on 31 January 2024.

“Access has always been core to pharmacy and an essential part of our offer to patients and the NHS. A decade of underfunding is putting this at risk,” says Malcolm Harrison, chief executive of the Company Chemists’ Association, adding that the decline in opening hours is “no surprise”.

“Whilst we welcome the rollout of the new Pharmacy First service and the accompanying investment, the developments of community pharmacy are based on the access offered by the network. These findings demonstrate the perilous position the sector finds itself in, with foundations weakened through a decade of underfunding,” he added.

The lack of increased investment in community pharmacy since 2017/2018 has already led to an erosion in the number of pharmacies available for patients to access. NHSBSA data published in October 2023 showed that, after 388 community pharmacies closed in 2022/2023 and 297 community pharmacies opened, the number of pharmacies in England is at its lowest since 2015/2016, with closures commonly occurring in more health-deprived areas.

“The reduction in opening hours has also been accompanied by a net loss of over 1,000 pharmacies since 2015,” says Harrison. “Taken together, this has created a perfect storm, with nearby pharmacies having to pick up the additional workload and patient access being hampered.”

Patient access

Louise Ansari, chief executive of Healthwatch England, which is part of the Care Quality Commission and champions patient views, says that patients are reporting increasing difficulty in accessing their medicines, partly because of temporary and permanent pharmacy closures.

“The reduction in opening hours across many pharmacies in recent years is likely to have further contributed towards these difficulties,” Ansari says.

“We are concerned about the reduction in 100-hour pharmacies, which particularly help working-age adults to conveniently get medicines for themselves and their families; and who also support people who need urgent medication for problems that develop out of hours.”

National Institute for Health and Care Excellence (NICE) guidance on end-of-life care says that all adults approaching the end of their life and their carers should have access to an out-of-hours pharmacy that can provide medicines to treat symptoms these patients might experience.

However, a report on assisted dying, from the House of Commons Health and Social Care Committee, published on 20 February 2024, said it was “very concerned” to hear evidence from witnesses who said that patients struggled to access palliative care medicines at evenings and weekends.

Sarah Holmes, chief medical officer at charity Marie Curie, says the fact that availability of out-of-hours community pharmacy is diminishing is “extremely concerning”.

“Terminal illness does not respect the clock. Access to palliative medicines out of hours can be complicated and time consuming but it needn’t be, and is crucial for people with a terminal illness, especially in their final year and months of life,” she says.

The number of 100-hour pharmacies proliferated under amendments to The National Health Service (Pharmaceutical Services) Regulations 1992, which came into force on 1 April 2005.

In an attempt to increase pharmacy provision and competition, the legislation introduced four exemptions to earlier NHS regulations that prohibited new contractors from entering the pharmaceutical list unless it was “necessary or expedient” to securing the adequate provision of pharmaceutical services locally.

These exemptions included pharmacies where the applicant committed to providing pharmaceutical services for at least 100 hours each week, as well as those located in large shopping centres, and those that would provide pharmacy services online.

Guidance for primary care trusts (PCTs) highlighted in February 2007 that having more 100-hour pharmacies would benefit “patients and consumers who, for whatever reason, are unable to access services during normal shopping hours”, such as shift workers or people who work in locations away from shopping areas.

“Those pharmacies prepared to open longer hours and extend service provision should therefore be able to do so unencumbered by control of entry,” the guidance said.

Changing regulations

However, the exemption was removed in a 2012 update to the NHS regulations, after a government white paper found in 2008 that PCTs were not able to control where 100-hour pharmacies opened, which meant there was “no match between the better access that a 100 hours per week pharmacy delivers and the need for such an improvement locally”. Additionally, the government found that there was a “clustering of 100 hours per week pharmacies close to each other”.

The updated regulations meant that no new 100-hour pharmacies could open, but stated that existing 100-hour pharmacies must maintain their opening hours. However, in May 2023, further amendments were made to the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013; one of which allowed existing 100-hour pharmacies to reduce their minimum opening hours to 72 hours per week.

Under the amended regulations, pharmacies that held 100-hour contracts would have to remain open between 17:00 and 21:00 from Monday to Saturday, and between 11:00 and 16:00 on Sundays, to maintain out-of-hours pharmacy provision.

The amendments were an attempt to address workforce and financial pressures facing community pharmacies but, at the time, Community Pharmacy England (CPE; then the Pharmaceutical Services Negotiating Committee) described the changes as “divisive”, bringing “some small relief to contractors of 100-hour pharmacies” while other contractors continue to struggle financially.

Since the amendments came into effect, the number of pharmacies open for at least 100 hours per week has declined dramatically.

As of December 2022, the pharmaceutical list published by NHSBSA included 942 pharmacies that were open for 100 hours or more, but by December 2023, there were only 197 — a fall of 79% (see Figure 2).

Confirmed by its own NHS data analysis, CPE says there has been both a reduction in the number of pharmacies opening for 100 hours each week and a reduction in supplementary hours offered by pharmacies with 40-hour contracts.

“All pharmacy owners are facing significant financial and operational challenges, leaving them with no choice but to make tough decisions to keep their businesses going,” says Gordon Hockey, director of legal at CPE.

“The reductions in pharmacy opening hours are a disappointing but necessary consequence of the continuing financial squeeze on the sector.

“Without a sustainable funding model, this trend will continue, reducing patient access to healthcare in the community. Government and the NHS must take action to reverse the damage that their historic funding cuts are causing.”

Monitoring local pharmacy provision

NHS England says responsibility for patient access to pharmacy services rests at a local level.

“Integrated care boards oversee pharmaceutical services for their local populations, ensuring services are available and responding to needs assessments conducted by health and wellbeing boards,” a spokesperson for NHS England said in response to The Pharmaceutical Journal’s analysis.

“The NHS is committed to supporting pharmacies across England to respond to local demand and developed new national guidance in May 2023 to allow variations to opening hours with their commissioner’s agreement.”

Jeff Blankley, chief officer at Birmingham and Solihull Community Pharmacy, says the local pharmaceutical committee has been tracking the changes in opening hours of 100-hour contract pharmacies, and that the majority in his area are now operating for between 72 hours and 83 hours per week.

The Pharmaceutical Journal’s analysis shows that the biggest losses in pharmacies operating for at least 100 hours between 2022/2023 and 2023/2024 were in Greater Manchester (53 pharmacies) and the West Midlands (55 pharmacies), with Blankley acknowledging that “many will now close earlier on weekdays and have reduced operating hours at the weekends”. 

But he stresses that most of the reduction in opening hours was for supplementary hours, and that he is confident core-hours pharmacy provision on his patch remained good.

The Pharmaceutical Needs Assessment (PNA) for Birmingham and Solihull, published in 2022, says there is “adequate” provision of pharmacies in the area. Blankley says that this “has not changed” but adds that the area “will embark on the 2025 PNA production in the summer when all the metrics will be reviewed”.

For other areas, the impact of declining pharmacy provision is apparent.

Like Jenkin (MP for Harwich and North Essex), Ian Lavery, MP for Wansbeck in Northumberland, also questioned Leadsom over the provision of pharmacy services, including 100-hour pharmacies. In response to his written question, Leadsom said on 30 January 2024 that, in December 2023, there were 5 pharmacies in the area contracted to provide services for at least 72 hours, compared with 6 in December 2019 that were contracted to be open for at least 100 hours.

Lavery says constitutents have raised several concerns to his office over the past year about their ability to access a pharmacy when they need it.

“We have also been contacted by those running pharmacies directly about the pressures they are facing,” he says.

“There has been an issue in Northumberland generally over the past few years and Northumberland County Council recently discussed it in their health and wellbeing board meeting.

“Pharmacies play a very important role in the ability of the NHS to operate, and the pressures being placed on community pharmacies seems to me intolerable, both for those running them and the community they serve.”

Figure 3: Reduction in hours for 2,381 pharmacies across England