The Pharmaceutical Journal
Vol 273 No 7319 p470-471
2 October 2004

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Community pharmacy must be better recognised as integral to the NHS?

By Hemant Patel and Raj Radia

Agenda series

A pharmacy’s brand is among its most valuable assets so it should not surprise anyone that the multiples protect their brands zealously. In a similar vein, the North East London Local Pharmaceutical Committee sees the promotion — or branding — of community pharmacy as part of the NHS as not only essential and urgent but also as mandatory. In this respect, we support an editorial comment about pharmacies being part of the NHS (PJ, 17 January, p42) since it implies that branding is about a “market franchise” and relationships, although the “NHS franchise” has yet to be fully defined and agreed. We believe that pharmacy should be talking about co-branding and not just about NHS branding. A brand is a complex, co-ordinated message to everyone about values and attributes and it must be consistent in all pharmacies and be sustainable over a long time.

However, we think the editorial comment that a direct link is made between branding as valuable step forward and lack of public awareness of the part that pharmacists play in primary care team is confused. Simply sticking a logo on to pharmacy fascia will not achieve a higher awareness or an enhanced role for community pharmacists. More thought is needed about what to do next now it has been agreed that NHS branding for community pharmacy is to be encouraged.

The essential question is not about branding, co-branding or cosmetic changes, but about positioning community pharmacy. So, the correct question is: “How can we ensure that community pharmacy is better recognised as an integral part of the NHS?”

We suggest three strands of work that need to be co-ordinated, resourced and developed in parallel when the issue relating to co-branding and integration is discussed: the right perception that pharmacy is part of the NHS, the right support from primary care trusts and the right infrastructure to do the job.

The right perception

If NHS branding is to be successfully applied to pharmacy for mutual benefit, then we believe four things are needed:

A mutually valuable relationship The NHS must be seen to appreciate community pharmacists and patients and pharmacists must buy into the values of modern NHS.

A strategically selected group of patients The respect and stature aspects of a brand can be as warm as sunlight and attract everyone, but the intimacy aspect of a brand should be like a laser beam. The target patient groups, particularly those with chronic need of medicines, should be identified and communicated with to ensure that the relationship is maintained. A link with hospital pharmacy and the elderly, in particular, is essential.

Brand definition The key emotional and visual elements, as well as the rational benefits, have been defined. What is the personality of the brand? What is its central organising thought? What does it stand for and against? Brand definition must be continually refreshed. New stories must be told about it. During the Labour Government of the 1960s, Prime Minister Harold Wilson insisted that a new topic be addressed every week. The current Blair administration clearly uses the same technique to keep the government looking on the ball. Is pharmacy ready for the public health challenge?

Consistent delivery Marketing communications must be consistent. So, too, does the delivery and, indeed, the stories told by employees at parties! Research suggests that loyal people are somewhat forgiving of occasionally inconsistent behaviour but this should not happen too often. This means that the clinical governance agenda and IT must be rapidly developed in parallel.

Mechanisms should be in place to ensure that co-branding is successful and mutually beneficial.

The right support

Napoleon Bonaparte said that ability is nothing without opportunity. Community pharmacy’s integration into the NHS will be much faster and better co-ordinated by linking community pharmacy to the single assessment process which, in addition to the political and public will, controls the commissioning process that up to now have been dominated by the medical model of health.

The integrated pathways of care approach to delivering clinical care offers a number of advantages and involvement offers pharmacists an almost unique opportunity to confirm their role in the team of professionals required to deliver patient care.

The research summary, “Developing community pharmacy — what pharmacists think is needed”, is based on a King’s Fund survey of 178 pharmacists in North East London. It examined the level of services they provide, their views on Government targets and the support they need to achieve these, along with the changes they expect to see in their own pharmacies. Pharmacists already provide a wide range of services far beyond those they are paid for and that are in their contract. The pharmacists surveyed were keen, and in many cases thought themselves able to take on the challenges laid down for them by the Government. But they also spoke of low morale and long working hours. The recommendations of the King’s Fund were:

· Adopt a proactive role With their new-found responsibilities, PCTs need to take on a proactive role in engaging with community pharmacists by commissioning services, improving partnership working and developing systems to involve pharmacists in their work. With a challenging future ahead, pharmacy services will benefit from the investment, support and skills that PCTs can offer.

· Ensure equal access to services Access to community pharmacy services must be universal. PCTs need actively to commission an appropriate range of services for patients, rather than pharmacists alone deciding what services to offer, sometimes based on commercial considerations. Our survey suggests that independent pharmacies are more likely than the increasing number of multiples to provide certain extended services. PCTs must, therefore, consider how to ensure equal access to a wide range of services.

· Develop services and skills Pharmacists need help from PCTs to develop their services and professional skills — particularly with training and premises improvements — if they are to deliver service improvement.

· Expand developmental capacity PCTs need to facilitate collaborative ventures between pharmacies to ensure comprehensive access to extended services. To do this, PCTs will have to expand their developmental capacity, perhaps jointly across a wider health community.

· Target investment Investment in services needs careful targeting. Not all pharmacists or pharmacies may be able to provide a wider range of services. Some may not be willing or able to undertake necessary training, and there may be limitations in terms of space and location (for example, patients should not be expected to receive counselling where confidentiality cannot be guaranteed).

· Extend clinical governance PCTs need to offer clinical governance support to community pharmacists. Although some pharmacists have already made progress in undertaking clinical governance activities, PCTs need to offer dedicated support if this is to be universal. Our survey suggests that multiples are more likely than independents to carry out clinical governance activities. There appears to be a trade-off between the range of service provided and its quality assurance. PCTs will need to work to ensure both.

· Support local pharmaceutical services schemes PCTs and LPCs — which represent the views of local pharmacists — have an important role to play in supporting LPS schemes. PCTs need to secure funding for these schemes to enhance the contribution of pharmacists to primary care. There is ample evidence that pharmacists have a key role in managing care (for example, through medication review), which will help to ensure better use of the health resources.

The right infrastructure

Community pharmacies can make a significant contribution to meeting the NHS challenges set out by the Government. However, these challenges can only be met if there is an infrastructure that helps pharmacists reach their potential. Unfortunately, this infrastructure does not exist.

Since 1987 the profit margin on NHS activity has fallen from 24 per cent to 13 per cent and, as a result, pharmacists 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. In addition, pharmacies face the threat of the loss of income from purchasing of generics.

Because of consistent mismanagement of human resources in the community pharmacy sector, owner-managers have left and are leaving the service in droves. (In 1989, 82 per cent of pharmacies were owned by owner-managers. By 1999 this proportion had fallen to just under 50 per cent. Without any Government intervention the proportion of owner-manager pharmacists is likely to decline even further.)

Pharmacists are now more 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.

These trends will have adverse consequences for patient access and it is likely to be deprived areas where need is highest, such as North East London, that will suffer the most. Community pharmacies are a key part of local economies and their removal is likely to destabilise local high streets (pharmacy visitors support other local shops and vice versa). Therefore, a vibrant community pharmacy sector is necessary not just to ensure high quality and efficient health services but as a component of the local social and economic fabric.

Conclusion

Pharmacists and the NHS must remember that with increased status comes increased responsibility for public accountability, quality and making pharmacies attractive places to work in. All national and local organisations must be involved in the production of a practical framework that can be readily applied to the branding and strategic issues that face community pharmacies as they seek to establish a new identity reflecting their traditional friendliness and informality with the new clinical and technological aspects of a modern and, we hope, an accessible pharmacy network.