The community pharmacy sector can help design a solution to the needs of the health service if NHS England and the Department of Health and Social Care (DHSC) set out a clear vision for what they want, and how they are going to pay for it, the chief executive of the Company Chemists’ Association (CCA) has said.
In an exclusive interview with The Pharmacist, Malcolm Harrison shared why the whole sector needs a clear plan for commissioned clinical services, without losing its core function of medicines supply; how the NHS needs to get serious about training prescribers; and why as a pharmacist, he is not afraid of changes to supervision.
Sector needs to know what the government will pay for in the long term
‘There are a lot of people with a lot of visions, a lot of them within our sector, ourselves included,’ Mr Harrison acknowledged.
But he said that community pharmacyneeds clear direction from the NHS and the DHSC as to what they plan to commission from community pharmacy in the long term, so that pharmacy businesses can invest appropriately.
‘Part of the challenge is understanding where does the payer want to go?’ he said.
‘Pharmacy is an interesting, unique sort of business model.
‘When you set up any business you look at the market [and] you want to see where does the customer want to go? What does the customer want?’
He added: ‘The customer is pretty much always the end user until you start doing dealings with government when the end user is the patient, and the customer is the NHS or the [DHSC].’
And he said it would help pharmacy businesses ‘immeasurably’ if there was ‘real clarity’ in what DHSC and the NHS want from community pharmacy in the future, ‘and how much they are prepared to pay for it’.
‘If you have that, then you can set about designing a solution,’ he told The Pharmacist.
Pharmacy, and community pharmacy in particular, has shown it is prepared to be ‘innovative’ and ‘step up and do things differently’, added Mr Harrison.
He pointed to the Covid-19 vaccination programme as ‘testament to the agility of the network to be able to step up and do something completely different [and] very new in a very short period of time’.
And he noted that this happened when government was ‘serious about it’ in terms of ‘what it wants to achieve, how it's going to go about doing it [and] how it's prepared to pay for it’.
In particular, he said that if the NHS set out a plan and a timeframe for what they will commission pharmacists to prescribe, that would be an incentive for pharmacy employers to train their staff.
But Mr Harrison stressed the sector needed a clear plan from the government and the NHS about how it will fund pharmacy services going forwards – with support for clinical services not squeezing out the sector’s core function of medicines supply.
‘It is safe to say the NHS sees the clinical capacity in future pharmacy as being an asset it needs,’ he said.
‘The NHS doesn't have enough nurses, doesn't have enough doctors, they’ve got loads and loads of patients who need to be seen and need to be treated. And so they look at the pharmacist population, the clinical capacity, and pharmacy technicians, and see an opportunity,’ he explained.
But he said that it was ‘really important’ that there was ‘an agreement as to what value’ the NHS and the DHSC ‘place on the supply function’.
‘What is the need from the clinical side of things? And how do we then work together to address those needs?’ noted Mr Harrison.
‘I'm a pharmacist as well; I'd like to see a more clinical future. I think that is where we want to go. But we can't do that at the expense of supplying medicines, which is core to what pharmacies do and is really important for the nation,’ he added.
Government must not let core dispensing be neglected
Mr Harrison warned against the NHS and DHSC asking more of pharmacies without paying more for it, especially as the cost of running a pharmacy business increases on all sides.
He said that there was a ‘danger’ that excitement around the additional £645m promised for clinical services community pharmacy – while a step in the right direction – could mean that ‘the core is neglected’.
While it was important that the government does its best to ‘make sure that the taxpayer payer’s pound goes as far as it can’, he said that it was possible to ‘go too far’.
‘You can spread it too thinly, and that is when the cracks appear. I think we we’re too thin at the moment,’ he said.
‘I truly believe that a competitive market and a free market is probably the best way of finding the solutions to provide for the NHS,’ he said.
But when measures intended to support a competitive market for medicines, like the retained margin, were put in place without being constantly reviewed and without a realistic vision for their future, ‘then they become outdated, and they kind of work against you’, he said.
In particular, he warned that controls like the Voluntary Scheme for Branded Medicines Pricing and Access (VPAS) might drive suppliers out of the market.
‘If you only end up with one or two manufacturers of something globally, [and] one of those gets shut down, then you've only got a single manufacturer left, and where's the competition? What happens to the price?’ said Mr Harrison.
He added that none of the efficiencies promised in the 2019 contractual framework agreement have yet materialised, making the cost of doing business even more difficult for community pharmacies.
‘We’re in year four, rapidly approaching the end of the five-year agreement and if they [DHSC] can't keep up their end of the bargain, it becomes very difficult,’ he told The Pharmacist.
‘A lot of the costings were predicated on the department delivering changes to hub and spoke, to supervision, to original package dispensing. And none of those have materialised, and are unlikely to before the end of this contractual framework.’
The CCA chief executive said that as a pharmacist, he did not feel hesitant about potential changes to supervision.
‘If we want pharmacists to be able to deliver clinical care, to be prescribing, they need to be released from the operational tasks,’ Mr Harrison said.
‘I think pharmacists need to understand why is it they're reluctant to let go of that control of things,’ he said, adding that pharmacists using locums or delivery services are already removed from some elements of the process.
‘I think somebodyor some organisation needs to show leadership in this, and actually say, “yeah, it is okay”,’ he said.
Mr Harrison also warned against relying on hub and spoke legislative changes to create savings.
A number of CCA pharmacies already operate hub and spoke models internally.
But Mr Harrison thinks that outsourcing dispensing is going to be a ‘tough sell’ for smaller businesses.
‘I think the reality is, when there is very little money in a margin in dispensing, to convince a business to pay someone else to do it for them, it is going to be a tough sell.
‘There's got to be enough margin in it for the actual person doing the assembly and supply to be able to afford to run that business. And there's enormous infrastructure, capital costs, upfront costs that are involved. That's not to say it won't happen. But I'm not entirely sure it's going to deliver the savings, or any efficiencies,’ he said.
And he said that any capacity released in the spoke would be ‘worthless unless there's something to do or commissionable services to deliver’. ‘And that's what's lacking at the moment,’ he added.
‘More money’ is not the answer
‘There isn’t an endless supply of money,’ Mr Harrison said.
‘So, the answer isn't more money. I think one of the challenges we face is what the public's expectation of medicines is, and what are we prepared to treat?’
‘You could spend 100% of GDP on health care, and it still wouldn't be enough,’ he added.
‘I think it is really important we try and understand: what is it the NHS is there for?’ he said.
‘Look at the number of average number of medicines per head of population in the country. 25 years ago, it was about nine, and now it’s over 18. So, we've become much more medicalised, as a nation [and] globally.’
And he echoed calls for a contract between the NHS and the public about what the health service was expected to deliver.
‘These are bigger problems than just pharmacy. These are big decisions that need to be made.'