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If the aspirations of pharmacy fulfilling a clinical role integral to public healthcare is ever to be realised, community pharmacists must shift their focus away from dispensing and towards NHS service provision.
The new report ‘Now more than ever’ — authored by Judith Smith, director of policy, and colleagues from the Nuffield Trust — assessed the short-term headway made in implementing the original recommendations of the Royal Pharmaceutical Society’s 2013 report ‘Now or never’.
The original 2013 report outlined the findings of the Royal Pharmaceutical Society —‘Future models of care commission’, chaired by Smith. The commission’s work could be interpreted as the latest in a long line of reports and policy documents — including the 1986 ‘Nuffield report: a signpost for pharmacy’ and the 2000 NHS national plan document ‘Pharmacy in the future’ — looking for pharmacy to fulfil its potential and secure the future of pharmacy in the face of transformative technology.
It is clear that, at some point in the near future, the current system of dispensing will be deemed unsustainable and pharmacy will need to reform to this brave new world.
Talking about revolution
If there is to be widespread reform by 2020, community pharmacy requires a revolution rather than evolution. Any revolution in community pharmacy is likely to be precipitated by a massive divestment in prescription dispensing in order to release money to help fund growth of NHS integrated care organisations. Indeed, the UK government may reduce the availability of NHS fees guaranteed to pharmacists (as happened with opticians and dentists in the past) so that more money is available for spending on the practice-based primary care team.
With substantial competition from big players and local practices keen to compete for the same work, the incomes of many community pharmacists will shrink rapidly
With the use of new technologies, dispensing in the community could soon replicate the dispensing systems used in hospitals. Indeed, policymakers are pushing for the replication of hospital dispensing arrangements in the community and have been quietly preparing for factory-type dispensing pharmacy outlets.
As the role of commissioning pharmacy services passes down to clinical commissioning groups (CCGs — NHS organisations that organise the delivery of NHS services in England), the cheapest supplier could be contracted to dispense all medicines in a locality, with patients receiving delivery of their drugs by mail or courier. Many community pharmacies would then shut. The cost of dispensing prescriptions to the community to the NHS could probably be more than halved, quite easily.
The money saved by reducing NHS dispensing costs could fund a smaller number of solo pharmacists to work on initiatives in patient care, with the work going to those who sell their services the best.
Alternatively, pharmacy chains, consortia of pharmacists and other interested healthcare providers could compete to provide medicine optimisation services to local CCGs. The remaining savings could then be invested in newly formed integrated care organisations. In such a world, there would be little need for a national pharmacy contract or independent contractors providing dispensing and related services.
Brave new world
A switch to service provision is therefore an unavoidable future for pharmacy. The development of medicines use reviews (MURs) and other forms of medicines reviews are closely akin to the US system of drug utilisation reviews. The UK system of MURs has been criticised for being conducted without full patient records. Indeed, for pharmacists to maximise their performance at offering medicine services they must be integrated fully into the NHS.
The implications for pharmacy practice are substantial. For independent community pharmacists, incomes will probably become reliant on the ability to provide services to patients rather than dispensing medicines
Therefore, the RPS Committee’s vision of a NHS led by integrated care organisations would better suit the provision of MURs and related activities than the existing system of isolated, community-based retail pharmacies.
The implications for pharmacy practice are substantial. For independent community pharmacists, incomes will probably become reliant on the ability to provide services to patients rather than dispensing medicines. With substantial competition from big players and local practices keen to compete for the same work, the incomes of many community pharmacists will shrink rapidly.
Multiples are likely to suffer as integrated care organisations take dispensing in-house or non-pharmacy health care providers establish dispensing businesses as adjuncts to other NHS contracting activities.
Can-do attitude
Policymakers, general practitioners and NHS commissioners need to hear a consistent “can-do” message from pharmacists about how pharmacy can help solve many of the challenges in patient care facing the NHS patient. The national community pharmacy contract, made between pharmacy contractors and the Department of Health, should be changed and new payment mechanisms should be introduced to enable pharmacists to assume a wider care-giving role.
Community pharmacy is in need of strong leaders with a vision that can unite internal divisions and persuade those resisting change to deliver the promise of greater involvement in patient care
Funding models must also be reorganised at a local level. Pharmacists must be relentless in making the case locally for their vital contribution to patient care.
If this does not happen, community pharmacy risks being overtaken by the expansion of technology-driven dispensing, and in pharmacy services being delivered by new NHS organisations.
Community pharmacy is in need of strong leaders with a vision that can unite internal divisions and persuade those resisting change to deliver the promise of greater involvement in patient care.
The strategy the report endorses can be seen as a “lifeboat” in which community pharmacists will need to jump into by 2020, when changes to the national contract and the introduction of localised integrated care will undermine the traditional model of a local retail pharmacy for local practice patients.
The current funding arrangements for pharmacy and model of care are unsustainable. Pharmacy should be empowered to let go of the dispensing function and seizes the opportunities on offer. If pharmacy fails to rise to this challenge, its role in the community beyond 2020 looks bleak.
Darrin Baines is professor in health economics at the University of Coventry
