Sink or swim: the future for pharmacy

A few years ago, improbably, I ended up presenting a BBC2 series, The Victorian Pharmacy. The unlikely storyline was that myself and two historians, gussied up in period clothes, were developing a high street pharmacy in Victorian times.

What sustained the series was the variety of inventive activities that the pharmacists got up to. Not just the expected making of medicines, but also dentistry, optometry, veterinary medicine, photography, making fireworks and perfume, and the development of fizzy drinks and food stuffs (baking powder was developed by a pharmacist who’s wife was allergic to yeast, and custard powder by one who’s wife was allergic to eggs). Dispensing was just a small part of the trade.

What came over in the series was the drive and innovation of the pharmacists, not least because if they failed to meet the needs of their local population they would become one of the bankruptcies commonly reported in the trade press.

However, over the following century the National Insurance Act, and later the NHS, made dispensing the commonest activity, and an increasingly lucrative one. Improvements in the manufacture of pharmaceuticals, regulation of medicines and changes to reimbursement mean that, today, most of a community pharmacy’s income is from the money they earn for dispensing.

Community pharmacy earns most of its money from the NHS, and so it needs to be responsive to its paymaster going through challenging times: improving quality while facing austerity, improving access, integrated care, meeting the needs of patients with long-term conditions and a significant reorganisation of commissioning in England.

Pharmacy also faces its own challenges: a national funding model that is moving from funding supply to provision of care and new supply models that are likely to develop from technology developments. So times – they are a-changing

The Royal Pharmaceutical Society recognised these threats and established the Commission on future models of care delivered through pharmacy in England. Led by Dr Judith Smith of the Nuffield Trust, the report – aptly entitled Now or Never – is a clarion call for action. It lays out the challenges to pharmacy and addresses what must be done to change community pharmacy.

The Commission is clear that pharmacists can provide value added clinical services for the NHS.  The report provides many person-centred examples in the areas of integrated working, primary care access, public health and medicines optimisation – the problem is that they are patchily distributed and poorly communicated. 

So why aren’t these models of care more widely distributed? This is the crux of the report. Several factors are identified, and they do not all make easy reading for pharmacy, our third largest health profession.

Firstly, community pharmacy is marginalised in the NHS and poorly understood by both the NHS and the public. It has lacked leadership and has a tendency to be insular.

Second, there is little career structure to build on a good education and training base and pharmacists often find themselves professionally isolated.

Last, and by no means least, pharmacy has suffered from poor commissioning of its services, with a ‘lack of courage to fund and incentivise a strategic direction...that appears…to be broadly supported across the profession and NHS’.

I have certainly heard many pharmacists articulate the challenge of being expected to invest to provide new services, yet being unclear whether they will be commissioned the following year. Those particularly interested in this area may wish to contrast the situation in Scotland (a world leader in pharmacy), where I co-authored a report on the future of pharmaceutical care earlier this year, and see the Scottish Government’s consequent plans for pharmacy.

The Commission has recommendations for many organisations and institutions: NHS England, The Department of Health, CCGs, local authority commissioners and health and wellbeing boards, and the Royal Pharmaceutical Society, to name but some. They can bring pharmacy into the broader vision and delivery of care to patients, however this army of authorities is not enough. Necessary, but not sufficient.

The onus falls to pharmacists – individually and together, managers and companies. Their risk aversion, which has served them so well as guardians of the safety of medicines, needs to be quelled by a spirit of endeavor. Their mantra needs to move closer to ‘it is easier to gain forgiveness than permission’, and push ahead with a sense of urgency. They could create new organisations, akin to barristers’ chambers, in which a group of them provide new services, perhaps across sectors.

In short, they need to rekindle that Victorian spirit of entrepreneurship in meeting the needs of local people. That is the route to success.

Nick is Director of Research at the Health Foundation.