The strongest impression one gets from talking to Steve Duncan, MRPharmS, Moss Pharmacy's managing director, is of the amount of study and planning the company is undertaking at the moment for developing community pharmacy services. The company is seeking to set out clear models of how it will move into what will certainly be a challenging and, potentially, rewarding future.

Community pharmacy is facing a testing time. Most of the systems through which it operates, and is rewarded, have been or are currently under review, either by external agencies or by the profession itself. These include the Office of Fair Trading's success last year in the resale price maintenance case and its current investigation into control of entry; the Department of Health's ongoing review of generic medicines and the long-awaited discussions on a new contract for community pharmacy; together with the profession's own debates on supervision, skill mix and continuing professional development.

Adding electronic transfer of prescriptions (ETP) and now local pharmaceutical services (LPS) contracts, it all points to a different way of organising pharmacy over the next five to 10 years.

Changing Moss

Two main events have influenced the Moss chain over the past 10 years. The first was the move from being an independent group (founded by Edgar Moss in 1912) to being part of the UniChem — now Alliance UniChem — organisation. The second was failing to secure the Lloyds Chemists chain, which went to rivals AAH. Now it faces a challenge of reorganising itself in the face of changes to the National Health Service. Steve Duncan succeeded the long-serving and much respected Barry Andrews at the end of 2000, and the succession took place at an opportune time, Mr Duncan says, as the company was then beginning its approach to forming a strategy to deal with the NHS plan and its pharmacy programme.

"I had an incredible opportunity to make the changes I wanted to, including the appointment of directors for NHS services and for information technology."

Moss Pharmacy has set itself what some might see as a fairly ambitious target of increasing the number of stores it has to around 1,200 by 2005. Whether the company achieves this target will depend on how the various changes to pharmacy remuneration mentioned above affect the market. The problems of an ongoing shortage of pharmacists and a trend towards greater locum work rather than full-time managerial posts will also need to be addressed.

"The target is to be between 1,000 and 1,200 branches. We are looking to achieve a critical mass that we are happy with by 2005, which will be somewhere between those figures. It does presuppose a number of things; principally how the market for pharmacies turns out over the next few years and the willingness of independent pharmacy owners to sell on to us when they retire," he says.

"We see no change in the general trend in the number of pharmacies coming on to the market at the moment."

One way of offering a greater service to customers would be to have, perhaps, a smaller number of pharmacies overall, each having two or more pharmacists present. Moss is taking a small step towards this with some of its new store formats.

"In our Total Health pharmacy format, the first of which opened at Cannock in Staffordshire last year [see PJ, 18 August 2001, p219], we have taken a view that this type of store should have two pharmacists present. This is what we think the business will look like in 10 years' time.

"As far as the public is concerned one pharmacist will be permanently available for them to talk to."

Technician registration

"On the wider picture, we need to look at skill mix and how highly trained technicians are going to be used," Mr Duncan says.

He notes that in the same way that pharmacists have said for a number of years that their expertise is underused, it is only reasonable to expect technicians to see exactly the same type of opportunity for enhancement of their role.

The Royal Pharmaceutical Society has decided that pharmacy support staff should be regulated and that the Society should take on this role. Mr Duncan offers his support for this.

"I think this should be a role for the Society. If the Society is going to be responsible for helping to develop pharmacy as a powerful force then it ought to be in control of the mechanisms for doing that.

"The reality is that we have a shortage of pharmacists. We could most probably develop pharmacy more — it would be a disaster if we failed to meet our potential because we did not fully developed the skills of everyone involved. It would be a crying shame."

Mr Duncan is also enthusiastic about checking technicians — "a good idea" — and says that Moss is looking at continuing professional development programmes for its technicians and pharmacy staff.

New pharmacy contract

The NHS contract for community pharmacy was last significantly revised in 1987 and has been showing its age recently. Negotiations for a new contract in England and Wales are just beginning.

Looking at what might be included in any new contract, and what might be retained from the existing one, Mr Duncan says: "Clearly the contract has to recognise the value pharmacy can bring to health care."

He adds that the plan will need the same level of resources currently required to provide dispensing services and that that part will need to be adequately remunerated.

"However, I think that within the remuneration there should be three elements: the dispensing service itself, the quality of care that can be given, and the level of services that can be provided."

As far as control of entry is concerned, Mr Duncan says he can remember clearly the time before the new contract and the amount of leapfrogging that went on. "It was clear that no-one would make a commitment to invest in pharmacy infrastructure because you could not be sure that what you were investing in would have any residual value. So, of course, the service was becoming polarised. It was an incredible relief when the contract limitation rules came in — even though we were still growing as a chain, we could be more certain of the future."

He hopes that the OFT will make a considered, clear and explicit announcement of its findings as soon as possible.

Primary care trusts in England will soon have responsibility for the pharmacy contract as reforms to the NHS devolve more power to a local level, a possible threat to pharmacy contractors.

Mr Duncan says that there is not yet sufficient clarity about the details of this to give a full answer, but he adds: "I think pharmacy is strong enough to be able to negotiate within the consultation period to ensure that this does not become a threat."

NHS services

Moss has been undertaking a lot of work at its head office, in its new NHS services directorate, looking at how the company and its pharmacists can respond to all the proposed changes in the NHS, work with primary care organisations and offer new services to patients. However, he does not believe that Moss can do this all on its own. "Inclusiveness" is one of his watchwords.

"As a company we have a policy of inclusiveness within pharmacy. This is a challenge and an opportunity for all of community pharmacy, not just one particular segment of it.

"Not to be inclusive would be an enormous mistake — if we do not get this right, if we do not actually work together to build a strong pharmacy sector, it would be an opportunity criminally missed. It seems to me that the old barriers about who can provide what in health care have been, at least temporarily, pulled down. It is the one time for us to be inclusive to build something really is substantial."

Moss now has over 50 pharmacists working between two and five days a week on local initiatives in primary care, as well as its head office team.

During the fallow year, Moss used around 60 pharmacists normally working either at its head office or in field-based management positions to work a few days a month at the company's branches, particularly over the summer months. "We supported them with return-to-practise training and, so far, the whole programme has been a success," Mr Duncan says.

CPD and prescribing

Another driver for getting head office pharmacists back out to the stores has been the forthcoming requirements for continuing professional development. If there is to be a division between "practising" and "non-practising" pharmacists, then Mr Duncan says that this will motivate staff to undertake appropriate training and gain relevant experience so as to stay on the practising register.

One area in which Moss is making heavy investment is continuing professional development programmes for its staff. The CPD programme for pharmacists working in its branches was launched on 8 April. Moss will reward its pharmacists for undertaking 30 hours of recorded CPD in a one-year period, on completion of the target.

The programme includes management workshops on topics such as communication, leadership skills and managing professional staff. These have been accredited by the College of Pharmacy Practice. Pharmacists have been sent a detailed CPD manual explaining the programme and how to record their own CPD activities.

The programme for branch managers will be followed by one for pharmacists in management and then ones for technicians and support staff.

You do not have to spend long with Mr Duncan to realise how keen he is on CPD and on developing detailed competency statements to underpin it. He believes that CPD and skill mix will determine how many new roles for community pharmacy, such as medicines management and supplementary prescribing, are taken forward.

"One reason why we are pushing CPD forwards is because we believe that there will be some form of accreditation linked to it if pharmacists are to undertake supplementary prescribing. We are already starting to look at some of our standard operating procedures to make sure we have looked at the risk management side of prescribing. So, we think we are in a prime position to take up this challenge."

Pharmacy medicines

One thing which community pharmacy groups are trying to do at the moment is to increase the visibility of pharmacy medicines, using either more open displays or, in some cases, undertaking trials of self-selection with the Society's authorisation. Moss is trying out self-selection at a small number of selected branches.

According to Mr Duncan, the issue that needs to be examined is why pharmacy medicines are kept behind counters at all. "If they are kept behind the counter because it is truly a good idea that patients cannot touch them and cannot handle them, then fine, but is that really the reason why they should be behind the counter? Are they there because it is just an easy way of ensuring that the pharmacist is always involved in every transaction?

"What it actually does is remove the patient's ability to handle the products. They are far more sophisticated. I feel that if we can develop protocols that ensure that our professional obligations to patients are still clearly exercised, so that the final decision as to whether that product is purchased or not remains with the pharmacist, then we can remove the barrier between the patient and the product. It has got to be better than what we have now."

However, if pharmacy medicines go on open display it could be difficult to differentiate them from other products sold in pharmacies and by other retailers.

"We need to look at this and say 'Can we improve patient access?', 'Can we improve the level of advice patients get?', 'Can we do it better than the way it is done at the moment?' and 'Can we ensure that the pharmacist is aware of all these transactions and intervene if absolutely necessary?'

"I think that purely the fact that you have got a counter there is not enough — what is the counter for? Mainly, it is to stop patient access, because we are saying that these are important products. But, if we can actually keep the importance of those products and improve patient access, then that must be better," Mr Duncan says.

Facing the future

Community pharmacy faces a challenging, somewhat uncertain but potentially rewarding future.

Speaking to Mr Duncan it is clear that Moss Pharmacy does not intend to go into this future unprepared. The company seems set to keep abreast of all the forthcoming developments, such as ETP, LPS contracts and the increasing amount of CPD its staff will need, but, like all community pharmacy businesses, it will have to hope that other changes to the pharmacy marketplace do not pull the rug out from under all its new developments.