After ten months of anxious speculation, pharmacy contractors and their staff have received the first concrete details of how the UK government plans to deliver cuts to funding payable to community pharmacies in England. When David Mowat, parliamentary under secretary of state for community health and care, addressed Parliament on 20 October 2016, he told MPs that the current payment structure for community pharmacy is outdated and overly complex and so will be consolidated into one single activity fee. Establishment payments, which pharmacies are entitled to claim if they dispense more than 2,500 items a month, will be phased out by 2018.
Every pharmacy will need to survive on less money or close for business. In England, funding for community pharmacy will be reduced by 4% for 2016–2017 to £2.687bn, starting from 1 December 2016. The 4% cut will be taken in its entirety over four months of the year, so contractors will experience a 12% pay cut in that period. This will be followed by a further cut of 3.4% for 2017–2018, reducing the funding to £2.592bn.
Up to £75m of the £2.592bn budget for 2017–2018 will be allocated to a new quality payment scheme from April 2017. Pharmacies will have to meet four criteria before they will be considered for the payment, including provision of at least one specified advanced service and ongoing use of the electronic prescription service. A focus on quality must be applauded but the scheme needs to be easy for contractors to navigate if it is to achieve its aims. And whether the quality criteria chosen by the Department of Health (DH) really will reward excellence remains to be seen.
The new pharmacy integration fund (PhIF), aimed at supporting the development of clinical pharmacy practice in a range of primary care settings, has been reduced from an expected £300m by 2021 to £42m over the next two years. The sector has been told that part of the PhIF will be used to fund a pilot study to assess a service to supply urgent medicines. However, messages coming from central government are inconsistent. Mowat has said on more than one occasion that a nationally commissioned minor ailment service will be rolled out in England by 2018, but the DH has denied this, saying it is more appropriate that these services are commissioned locally.
Also, the government continues to distance itself from a prediction made early in 2016 that up to 3,000 pharmacies could close as a result of the cuts. “Nobody is talking about thousands of pharmacies closing”, Mowat told MPs in response to an urgent question in the House of Commons on 17 October 2016.
Is subsidy enough?
A pharmacy access scheme, where those pharmacies that have been identified as being either in an area of deprivation or where community pharmacy provision is sparse, will qualify for a monthly subsidy from December 2016 to March 2018. Again, this provision should be welcomed but the jury is still out as to whether the payments — available to less than 12% of all pharmacies in England — will be enough to protect vulnerable pharmacies from closure.
The DH’s impact assessment document, released alongside the funding cuts document, says there is no reliable way of estimating the number of pharmacies that may close as a result of the cuts. If it is not possible to estimate the number of closures, then it is impossible to measure the potential impact on patient care, particularly for vulnerable patients within the community. The stakes are too high for this wait-and-see approach.
The DH contends that, were a pharmacy to close, it is likely that prescriptions that were dispensed by that pharmacy would be redistributed to nearby pharmacies, and this will improve the viability of remaining pharmacies. However, if a pharmacy that offers several clinical services but has a low dispensing volume closes, patients may lose access to a vital service. If pharmacies respond to the cuts by reducing their opening hours and making staff redundant, it will not only reduce the accessibility of community pharmacy services, but clinical quality, too. And services that contractors are not obliged to offer will be the first to go — such as home delivery of medicines and the supply of medicines in compliance aids. It is clear that the impact on patients has not been considered.
Lack of foresight
The government continues to command hardworking healthcare professionals across all sectors to “do more for less”. But it is yet again failing to convince those same healthcare professionals that its plans are carefully thought through or to demonstrate that it has a firm grasp of the consequences for patients and the public — a cavalier approach with every prospect of deeper cuts to come.
While pharmacy organisations try to make sense of the details released, the sector has been given lots of answers for questions that perhaps the government is not in a position to answer. But the sector must do all it can to engage with the process, prove pharmacies’ worth to the NHS and protect vital service provision and patient care.