The Pharmaceutical Journal Vol 267 No 7163 p292
1 September 2001

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Turning aspirations into realities

By Gary Boorman, Jay Patel and Shiv Bagga

Community pharmacies can make a significant contribution to meeting the challenges set out for the NHS by the Government in “Pharmacy in the Future” — but only if there is an infrastructure in place that supports pharmacists in reaching their potential. Unfortunately, such an infrastructure does not exist. Indeed, the current organisation of pharmacy services is such that the community pharmacy contract and financing arrangements are placing community pharmacy services in great jeopardy.

Pharmacists in 2001 are working longer hours, taking shorter holidays and cutting investment in their businesses. Morale among community pharmacists is dangerously low and without urgent action the NHS faces the potential for large-scale and unplanned closures of pharmacies, especially since the abolition of resale price maintenance. Pharmacists are reluctant to own pharmacies and play a full role in community development. Pharmacy is now characterised by a rapid turnover of professional staff and an explosive growth in the use of locums. The result is a degree of instability that is impeding the professional development of services and their integration into wider primary care. There is, therefore, a need for incentives to encourage pharmacists to put down roots in the local community and to re-establish the continuity that used to be a hallmark of the community pharmacy sector. The current trends will have adverse consequences for patient access and it is likely to be deprived areas that will suffer the most.

London’s community pharmacies have suffered the same level of under-investment as that which characterised GP and community health facilities up until the early 1990s. However, the London Initiative Zone that invested £400m into primary medical and nursing services did not address community pharmacy. Health authorities have little power or resource to work with community pharmacies to create a modern network of service providers.

We recommend that the NHS Executive and health authorities are empowered to work with community pharmacies to improve the infrastructure. In particular:

• To develop a capital investment strategy that supports a network of high quality pharmacy outlets delivering excellent access
• To introduce technology that links community pharmacies to the NHSnet and develop appropriate software to facilitate interprofessional partnership
• To invest in human resources to ensure that pharmacists are adequately motivated and remunerated and enabled to develop professionally (including a prescribing role) and remain in a given locality

We recognise that change is necessary and that pharmacists themselves cannot stand still. We recognise that our relationships with other parts of the NHS will need to be re-evaluated and we can see the benefit of new organisational models that more closely integrate pharmacists with other parts of the NHS. Above all, we recommend that the national contract to which all pharmacists are subject is reviewed and amended so that it supports, rather than hinders, the service developments that we have proposed for the benefit of the public.

The current contract for community pharmacy provides few incentives to deliver high quality professional pharmaceutical services. Instead, the contract rewards the dispensing role of the pharmacist at the expense of other professional services. This ignores the significant development of new concepts of “pharmaceutical care” that places emphasis on responsibility (with others) for the effects of the therapeutic process.

In Barking and Havering, work has taken place between the health authority and the local pharmaceutical committee to explore new contractual possibilities, in particular, to design a contract that provides positive incentives to develop an extended range of services in addition to the dispensing role. While powers to introduce such a scheme do not currently exist, the LPCs and health authority recommend that greater contractual flexibility is required. This would bring community pharmacy services into line with GP and dental services where greater flexibility has been delivered through personal medical services (PMS) and personal dental services (PDS) pilots. This recommendation has been accepted and local pharmacy services will begin in the near future. We, also, recommend that a new contractual approach is developed that is based on a number of key principles:

1. There must be comprehensive access to a full range of pharmacy services for all the population
2. Services should be actively planned and managed on a locality basis to ensure good access and stability in terms of personnel and premises
3. Services must be quality assured and pharmacists take part in locally appropriate professional development
4. The role of pharmacies in contributing to the wider social infrastructure and economy should be recognised within the planning process
5. The voluntary and compensated closure of some pharmacies should be facilitated, where appropriate
6. The contract should guide, manage and grow intellectual capital — offering a framework upon which community pharmacists can build useful and valuable strategies for meeting health care needs as near to the patient as possible in the Information Age

A new contract should, where appropriate, encourage greater economies of scale by facilitating relocation or a reduction in the number of pharmacies through a planned and locally negotiated process. It should recognise the core role of dispensing and medicines management of community pharmacy. By contractual means it should change the culture to promote regular multidisciplinary working, training and education (while recognising the cost implications of ongoing professional development). It should shift the balance of remuneration towards securing extended professional services. It should provide additional support for “necessary urban pharmacies” ( a scheme adapted from the Essential Small Pharmacy Scheme. It should acknowledge and satisfy the need for target income to ensure stable and viable network of pharmacies.

The contract should resource local pharmacies to provide “pharmaceutical care” to the community and to collaborate with health and social care colleagues. The contract could be used to focus pharmacy services on a range of quality standards including: premises standards, patient medication records, a personal development plan, dispensing standards, participation in tailored local health promotion schemes, participation in audit, disposal of unwanted medicines, participation in a formal referral scheme, and demonstrable understanding of care pathways in key diseases.

Other extended pharmaceutical services could be commissioned by the health authority or primary care group, including: domiciliary pharmaceutical services for patients identified by their GPs as on complex medication and housebound, advice on prescribing to GPs, complex medication review (ie, providing advice to patients at a surgery or pharmacy), chronic disease management within local protocols for defined conditions on referral from a GP, oxygen supply, advice to residential and nursing homes, and out-of-hours dispensing services.

If community pharmacists are to play a full role and one that maximises their contribution to health care, root and branch change to the infrastructure of pharmacy services will be required. To do nothing will consign community pharmacy services to an uncertain future.

The Government has stated its desire to work with pharmacists to extend their role. The National Plan for the NHS is a perfect opportunity to turn aspirations into realities. Pharmacy in the Future should now be adequately resourced to make change happen.

The authors are all chairmen of North East London local pharmaceutical committees