Janet Morrison: ‘Any contract reform is likely to have winners and losers’

Weeks on from the community pharmacy contract announcement, things are still busy for Community Pharmacy England (CPE)’s chief executive, Janet Morrison.

Since announcing the new deal — which includes a 10% uplift in the global sum, to £3.636bn; the introduction of independent prescribing within Pharmacy First; and a £239m margin write-off — the negotiator has spoken to more than 600 contractors via a webinar and regional events.

Feedback on the deal has been “very balanced, actually”, Morrison says, with responses ranging from “disappointed, better than expected, not enough money, hopeful for the future”.

“The independent chair, Dame Jenny Harries, was saying there was nothing she heard in the regional meetings that she hadn’t heard in the committee itself, because we’ve got the same mix of views,” she says.

“The committee have made it very clear what it feels like at the front line, and we fed that into government, so the minister is very well informed, I would say.”

After a “little pause” for committee meetings, Morrison says she’ll be “back on the road” to speak to more contractors, as well as beginning the programme of work, including a commitment to reform, that was agreed as part of the 2026/2027 ‘Community pharmacy contractual framework’.

What do you think is the biggest win in the contract for community pharmacists?

One of the most important headlines is just the overall quantum of the deal, [an uplift of] 10.3%, which obviously is not enough. We’ve calculated that it will cover the growth and activity and inflation that we’re projecting for the year. It doesn’t go far enough to do anything about the underlying funding gap, and closing that gap, and to building to sustainability. But I think it’s important because it does show that ministers are listening and they are giving us again a generous deal compared with others in primary care. It’s also important because they are trying to reset margin. They’re concerned about the safety of medicine supply, so that adjustment to the margin allocation and to the write-off is them hoping to stabilise that system.

I guess one of the most important headlines will be about independent prescribing (IP), and that’s quite a mixed story. All my committee members think IP is strategically important and that we want to be able to draw in independent prescribers to community pharmacy to feel that they’ve got a rewarding role to play, building on all of those IP pathfinders, which demonstrated the real value. 

But our concern is because it’s such a constrained envelope, there’s actually not enough money in the contract to really set it up with a solid foundation. Looking at the work we’re going to have to do behind the scenes on clinical governance, assurance, the infrastructure, digital and workload, we argue very strongly it’s not enough money to do all of that.

We were saying it should be a national enhanced service, so you set the framework for it nationally, but it’s commissioned locally, or next year [the government should] come back with the right full level of investment. I guess the jury’s out on where we go from here. 

Within this financial year, what do you think might be possible for the current set of prescribers in community pharmacy? 

Our view is [contractors] should think really carefully about whether to actually engage with the service. There are existing independent prescribers in about 20% of pharmacies, but even new independent prescribers coming out of pharmacy school will need a considerable amount of peer support and structure around them, so our concern is it’s just not enough to start it up in a full and committed way, given the workload involved.

Is there enough for 20% of community pharmacies to be delivering a prescribing service? 

We don’t think the way the funding is structured and the way that it’s being set up that it is really sufficient to do that.

What proportion of pharmacies do you think could begin to offer prescribing?

I really don’t know. There’s nothing stopping pharmacies from using independent prescribers in private services anyway, and many do already, and I think that’s likely to continue, but I can’t really say what the take up [of the NHS service] will be. People have to make their own judgment.

One of the concerns, for example, is the payment for Pharmacy First consultations [using prescribing] is the same as with a patient group direction, and that doesn’t reflect at all the responsibility and level of clinical judgment involved, and the insurance that’s involved with that. Or if you look at the costs of the CLEO system [used for prescribing in pharmacies], we don’t think the fees will recompense for that kind of infrastructure cost.

Paul Stuart

Is the appetite there from the government to do that?

I think they want it to be successful. This has been a long time coming in terms of getting independent prescribers out there. They can have a really valuable role, and that came out in the pathfinders, where it worked really well. 

I think that’s the direction of travel [government] want to go in. Our challenge is that the overall [funding] envelope is constrained. I’ve got to be honest, if there had been loads of money in IP, then the four-fifths of pharmacies who don’t have an independent prescriber would have said: “Why is the [single activity fee] so low, and why haven’t we got more money in that?”

It’s not going to be straightforward for us, in terms of different types of pharmacy having the capability to access funding. It is going to be a dilemma for the future, but they definitely want it to be successful. 

The pathfinder evaluation highlighted the value of pharmacies in long-term conditions medicines management, which was not commissioned. Did that come up in discussions at all?

I suppose at this stage what’s being proposed is a fairly limited range of clinical areas that the independent prescribers could activate. We talked about the scope of the pathfinders and how much has been delivered, but really a lot of our negotiation was around affordability. If they had stacked in loads more conditions, loads more areas where the independent prescriber can make a difference, that was going to cost more money and the global sum isn’t sufficient to be able to provide that. But I think they’ve seen the potential of it and I definitely think that’s understood. And that goes for the long-term condition management, it goes for some of the women’s health areas that have been picked up, migraine, menopause, all of those sorts of different areas where there’s great potential. I think they saw this as the starting out of that journey, but they couldn’t really afford to put it in, in a more ambitious way.

Does the government have a planned timeline to make up funding to the amount that’s needed to deliver NHS services?

I think obviously the sector has got an enormous allergy to long-term funding deals after what happened before, but going year on year, subject to the latest spending review and budgetary choices, is not really a good way to say you’ve got a roadmap for the future. Last year, there was a commitment towards looking at the sustainability and operating model for community pharmacy, and that didn’t happen, so it is important that we do the thinking now that has longer term perspective.

Why didn’t that happen last year?

If I’m really honest, I think it was around the changes that are going on in the Department of Health and Social Care, NHS England and capacity. I think their capacity has been hugely constrained by the merger with NHS England. I don’t really want to make excuses for that, because also there’s an element of, we do negotiations, and then there’s implementation to be done, but those bigger conversations don’t happen. We’ve got to make sure they do happen now, though.

I hear a lot about automation and hub and spoke. I have been in pharmacies where I’ve seen their use of robots and automation and certain types of systems, and I’ve been able to see they’ve helped efficiencies in terms of staff costs and or freed up the staff’s time for more consultations with patients, rather than simply the bagging up and counting of medications. So I can see the value of that, but sometimes I hear NHS England people talk about [automation and technology] and I think — what are their assumptions about that? Is it that distance-selling pharmacies and hubs can do all that? Well, we need to surface that, because we also know the relationship between dispensing and services is really fundamentally important, because it’s that face-to-face contact and added value to that act of handing over the medicines, so we can’t divorce them entirely.

Paul Stuart

In terms of community pharmacy reform, how broad do you think the government is happy to go? 

That’s all up for debate. If you’re looking at the future of the network, what is it that government needs the network to deliver, and are there different scope or roles for pharmacies? 

If I took 20 people in a room, and I say: ‘What do you mean by contract reform?’, I’d get 20 different answers. I’m not sure that everyone knows what they mean by contract reform. I think a lot of people think it means more money, and of course, we hope that is part of an outcome of it. But any contract reform is likely to have winners and losers, any change in the way that you commission or you support different parts of the contractual framework, there’ll be winners and losers.

We don’t know what the answer is going to be, but — and this could be unpopular — I don’t think it’s turning back the clock to ten years ago and just being rewarded suitably for dispensing and services. It’s got to be something different, which is: what does a healthy community pharmacy network look like that’s meeting the needs of patients and communities and adding the most value to the NHS? And I don’t think there is a consensus on that.

If you’re not talking about being rewarded for dispensing or services, what are you talking about?

We are going to talk about those, but what I’m saying is, what kind of network do we need and then what are the incentives, the funding and contractual frameworks that support that direction of travel? 

It’s not simply dispensing and supply versus clinical services, we’ve got to marry the two to enable that interaction with patients. 

So, you could have a big hub here, a pharmacy just doing services there — not even worrying about dispensing — and then another offering both?

We’ve got to entertain that idea, to think about it. Traditionally, we’ve said there’s one contractual framework for everyone — and there is — but we have actually got essential service, and we’ve got advanced services, and you don’t have to do the advanced services. I would say that a lot of the sector has absolutely embraced the clinical services in a huge way, but I can also say that some might have been driven to do that because of economic realities. 

What’s to stop the government kicking the can down the road while the sector is struggling?

That’s our role, then. We said our support for this deal was highly conditional on that work programme, and that’s why we’re meeting with the minister, and we’re going to make some public commitments to what that’s going to involve, but it doesn’t mean the answers are easy to get to, so we need some quick wins to demonstrate to people that that’s going to work, but also some more fundamental questions.