It is no secret that community pharmacy’s darkest days may still be ahead.
Shortly after the Pharmaceutical Services Negotiating Committee (PSNC) agreed the ‘Community pharmacy contractual framework for 2019/20 to 2023/24’, Ernst & Young published a concerning report warning that, without additional funding, up to 85% of community pharmacies in England will be in financial deficit by the time the contract ends.
Now, as community pharmacy enters its fourth year of the five-year deal and despite multiple failed attempts by the PSNC to secure an uplift, time is running out. The sector has already seen a record number of closures, with official data from NHS England confirming that closures in 2020/2021 have resulted in the lowest number of pharmacies in England since 2015/2016.
Meanwhile, in the pharmacies that remain, the PSNC has reported a doubling in clinical workload, as changes to legislation around hub-and-spoke dispensing and enabling better use of skill mix, which were promised to release pharmacists to provide other services, have still not happened.
However, there may be cause for hope. Community pharmacy has a new face at the negotiating table, with Janet Morrison joining the PSNC as chief executive in March 2022, just as negotiations for the fourth year of the contract began.
Until recently, Morrison was chair of The Black Stork Charity, which promotes clinical rehabilitation for members of the Armed Forces and supports rehabilitative medicine more widely, and chief executive of the charity Independent Age, where she advocated for the needs of older people.
The Pharmaceutical Journal sat down with Morrison to get her fresh perspective on where the sector is headed after the five-year deal ends and beyond, as she devises a new “vision for community pharmacy”.
Having spent 11 years as chief executive at Independent Age, how do you think community pharmacy can provide more care to older patients?
When I was working at Independent Age, we spent a lot of time navigating the health and social care system. What really surprised me when I came for this job was that I realised how rarely we thought about the role community pharmacy played. We never really thought about its role as the community hub for health and wellbeing, and its potential for dealing with all sorts of things in terms of health inequalities and people with long-term conditions.
And so, it just suddenly seemed like a bit of a no brainer to see the connection with community pharmacy: valued, trusted, expert and completely accessible. There’s real scope for that role to be enhanced as being the hub in the community that’s accessible in a way that relieves pressure on GPs and on emergency departments.
Is that something you’re proposing in the contract discussions at the moment?
The contract discussions are confidential. There are some important points, though, that we are making. One is demonstrating the value of what the sector has delivered during COVID-19. But also, unfortunately, just when that could be a build to say, ‘Look at the ambitious programme that we could deliver’, one of the other things we’re charged with raising is the funding pressures and capacity pressures on the sector. That’s what we’ve raised in the negotiations.
If, as we’ve heard, there’s no funding uplift to come, what is your prediction for where community pharmacy will be at the end of this contract?
If there’s no uplift, I think we’re in a pretty tough place. And we’re going to start seeing the results of the funding and capacity pressures. So that might mean closures. It might mean more cuts in opening hours. And it might mean temporary closures because they just can’t get a pharmacist.
Also, already contractors are making choices about whether to sign up for all the advanced services now, or whether to take a pause to embed what they’ve got. And some may even think about pausing doing the advanced services at all.
So, I’m really worried that unless we can do something to inject some more resource into the sector, by the five-year point, we’re going to be in a bit of a bad place. As someone new coming in, that’s really disappointing and challenging, because there’s so much potential for a wider role for community pharmacy. The NHS has huge waiting lists of people. It makes complete sense for them to be moving more of that first point of contact out into the community pharmacy sector. But the risk is that we’re hitting that tipping point now where they won’t be there to be able to respond to what could be a really ambitious future.
Do you think you’ll get to the stage where the PSNC would tell contractors to stop providing advanced services to stay afloat?
I can’t say where we’re going to end up. But from what I’ve heard through the committee and from contractors, there are a lot of people who are saying ‘we can’t take anything more on’. So, you could put the most attractive service on the table for us that would be scalable and make sense for the long term, but we haven’t got the capacity to respond. I think it’s quite likely that people are going to say that. It could well be that people will just say ‘I can’t take on anything more right now’. That could well be a response from the PSNC because of what we’re being told.
Would the PSNC consider taking the lead from GPs and pull back from providing parts of the contract?
I don’t think we’ll take our lead from GPs in the sense that we’re in a different place to them. We’ve noted that they got a settlement enforced on them and that they’re making a lot of noise about that and the consequences. But I feel certain that there will be conversations like that with the committee about the consequences if we can’t get any additional funding or recognition of capacity constraints, but that will all be discussed.
Has Pharmacy First been raised in negotiations?
I can’t answer that. But I would say that we’re very aware of what ministers have said positively and about the model in Scotland. I’ll give you a hint that probably not. But in the future direction of travel, those sorts of things should be things that we’re talking about.
[The press office clarified after the interview that walk-ins, including funding for them and the expanded role that pharmacies could play, are very much a part of the bids the PSNC is putting forward in the Year 4 negotiations.]
Once this five-year deal is complete, will the PSNC be looking to make another five-year deal?
I don’t yet know the answer. We’ll do the best that we can do at the moment to make the case for community pharmacy in terms of its viability and sustainability. What we absolutely have to do is start thinking ahead to what happens at the end of this settlement — there are arguments either way. The benefit of a five-year deal is that it gives people something to plan with. The downside is the public finances are under huge pressure, and that might mean that you’re not going to get as good a deal.
Pharmacy closure rates halved in 2021 compared with 2020. How should this be interpreted? Is this a sign that pressures are easing?
There are two things that have sort of masked some of the underlying downward pressure on resources. One of them was that injection of additional COVID money [which contractors were able to claim in 2021]. The second thing is margins. So, we’ve been getting a larger margin through on medicines, but that will have to be corrected, because that’s the system and it hasn’t been corrected yet. So that may have an impact.
I’ve spoken to people from large multiples and small local independents, and they’re all under severe pressure. With a smaller independent, people will hold on as long as they can because it’s their family business. That doesn’t mean it’s in a healthy state at all.
If you only go on closures as a measure of the strain that we’re under, it doesn’t tell the whole story. We have to think harder about how we can demonstrate in a number of ways the real results of the pressure, and that will be on things such as opening hours, the level of service that’s offered and the time spent with people. We probably need to be able to articulate that a bit better.
How are those smaller independents staying afloat?
I would say people are digging into loans or into their own resources. They’re putting more hours in and using less staff. So they’re putting more of the hours in themselves. And, anecdotally, someone said to me, dipping into their pension funds.
But I need to see it. This job is not just reading the papers, but it’s actually going out to see and visit contractors. I will be visiting some to hear their story about how they are coping, but what they’re prepared to say about the actual impact on them personally, that’s up to them.
Is the PSNC any closer to understanding how many pharmacies the government would like to see close?
No. I think there was a perception a few years back, when the funding was cut, that the government thought there were too many pharmacies and, potentially, that markets correct themselves. But we’ve got no picture of that and no one’s saying that to us at this moment in time.
Has this idea been dropped by the government?
Who knows? We probably need to surface some of those assumptions. What I want to spend time doing now is thinking beyond the five-year deal and actually asking about the vision for community pharmacy over the next five years. I want to work with the other sector bodies, but I also want engagement with the government and the NHS to really say, ‘what do we want and let’s align our visions’. We will need to surface some of those assumptions if they exist.
How will the PSNC decide on that longer term vision for community pharmacy?
What you need to do to come to that view is really engage with contractors. It would be quite easy for us to just be in this regular cycle of dealing with the next round of negotiations. But we do need to start taking the time to be looking outward and thinking about how the world has changed. Also, how consumer behaviours are changing and how we’re going to respond to that.
So, longer term, they won’t be the PSNC’s major areas of influence or responsibility, but workforce has to be one and also digital engagement. That’s something a sector needs to think about in the future.