The future of pharmacy in the UK

Pharma companies rely on doctors to prescribe the medicines they produce and pharmacists to supply the drugs selected. Recent discussions suggest that pharmacists are keen to move away from their role as dispensers and to be involved, to a greater extent, in patient care. Therefore, understanding the policy agenda and the possible rate of change is vital in gauging the likely impact of the changes ahead.

Community pharmacists have traditionally been the cornerstone of NHS care. They have almost silently supplied the billions of prescriptions for medicines issued by general practitioners since the inception of the health service in 1948. However, the role of dispenser of drugs is being challenged on three fronts. Against this background, both NHS England and the pharmacy profession are keen to discuss the way ahead.

For pharma, the desire to change the way in pharmacists work raises a number of interesting questions for pharma. Will community pharmacists become more involved in drug choice or management? Will community pharmacies disappear from the high street? What do the changes mean for NHS and over-the-counter sales? For these questions to be answered properly, we first need to ascertain whether the proposed reforms are likely to occur, and within what time frame? In response, this article explores proposed changes outlined just over a year ago by the Royal Pharmaceutical Society (RPS), and examines progresses to date. It concludes that, without a radical reduction in the fees paid for dispensing, community pharmacists will have little incentive to find new roles for themselves. Therefore, for now the proposals may be more aspirational than real.

Now or Never

In November 2013, the RPS published Now or Never: Shaping Pharmacy for the Future. Based upon the Society’s Future Models of Care Commission, the report was intended to create a coherent narrative for pharmacy reform. Chaired by Dr Judith Smith, director of policy at the Nuffield Trust, the Commission brought together expertise from across pharmacy, the wider healthcare sector and patients. The Committee’s approach was very similar to a number of previous studies into the future of pharmacy, starting with the Nuffield Report in the mid-1980s. To the frustration of many within the profession, for decades there has been constant thinking and talking about the best way ahead, but with little real progress being achieved.

The report of the Now or Never Committee started with the assertion that community-based pharmacists could do much more for patients. In an environment of diminishing NHS resources, patient care must be improved without increasing public spending. Since 2010, there has been zero growth in the NHS budget for pharmaceutical services. This situation is likely to continue in the foreseeable future. Against the background of fl at budget growth for pharmacy services, there has been a steady growth in the demand for medicines, rising at a rate of about 4% per year. As less and less money is available to dispense more and more medicines, in the medium term new technology may take over significant parts of dispensing and supply. In the UK, some hospital pharmacies have used robotics (supported by changes to skill-mix) to perform the dispensing function. With falling incomes and growing pressures to cut costs, community pharmacies may have to follow suit or be forced out of business.

Pharmacists are marginalised within the NHS and not sufficiently integrated into care teams

Models of care

The Commission asked for submissions describing different models of care involving pharmacy. Chapter Four summarises these submissions. The Commission reported that many pharmacists are keen to develop innovative ways of delivering patient services, particularly under the banner of medicines optimisation, integrated care or public health. However, Now or Never states, “The most striking aspect of our analysis of these many models of care is that they remain exceptional and hence ‘innovative’ when arguably the majority could and should be mainstream, given presenting health needs, years of discussion and writing about broadening the role of pharmacists (especially in the community), and the apparent hunger within pharmacy to ensure that skills and experience are used to maximum patient and population benefit.”

The key challenges in pharmacy 

As an indication of what is possible in the future, Now or Never reported that over 100 examples of models of care delivered through pharmacy were received. These were categorised in terms of their focus on: (i) access to medicines, advice and care; (ii) optimising the use of medicines; (iii) improving public health; and (iv) new integrated ways of working. The Commission found evidence that models of care had been implemented in all categories, despite significant barriers to change often reported as stopping innovation. Now or Never reported that, “Pharmacists are forming new networks and organisations, often in collaboration with other health professionals, to design, bid for and deliver new models of care.” Despite a widespread consensus that pharmacists should engage more in the delivery of health services, the Commission found that examples of such care remain relatively rare and are generally considered as being innovative.

Making change happen

With good ideas for improving patient care so readily available, the Commission asked why aren’t the identified models widely used? In response, Now or Never reported that pharmacists are marginalised within the NHS, and not sufficiently integrated into care teams. Moreover, pharmacy is poorly understood and lacks sufficient national and local leadership. Despite new training and education opportunities, many pharmacists are frustrated at their professional isolation and lack of time to engage in local health service design and development work.

To make change happen, Now or Never made a number of recommendations. Notably, the report suggested that the pharmacy profession be proactive in pursuing change, particularly by developing new models and adopting new roles. Moreover, the report recommended that commissioners be bold in purchasing innovative pharmacy services, while new bodies like hospitals and Local Authorities should commission pharmacists to do work. However, a key driver of change would be the adoption of new technology, which would free up pharmacist time to perform activities other than dispensing. In conclusion, Now or Never reported that there has been more than enough analysis of pharmacy. As a result, what is now needed is action. Indeed, “Pharmacy is in some ways its own worst enemy, having spent over 20 years pointing out that it is under-utilised, writing plans and visions for the future, yet seeming unable to influence in a significant manner the commissioning and implementation of this alternative world.”

RPS response

The profession’s response to Now or Never is vital in determining whether innovative models of pharmacy-led care become widespread in the NHS. Over the last year, the RPS has been making steady progress responding to the report and is keen to promote the adoption of new models of care, but widespread adoption and reform are still in early development. Therefore, it remains debateable whether fast enough action may be possible relying solely upon initiatives within the profession and good intentions by innovative commissioners.

To achieve the revolution that Now or Never suggests is necessary, NHS pharmacy requires wide scale reform. For pharmacy-led services to become commonplace, NHS England must significantly reduce the dispensing fees given to community pharmacists and create incentives for them to do something else. However, pharmacists are a strong political lobby and the NHS leadership has many existing problems to solve without creating new ones within the relatively calm area of pharmacy. While some pharmacists may be frustrated at the waste of their skills, the owners of pharmacy outlets will not petition their leaders to cut their fees for dispensing just so they can work harder creating new ways of earning a living. In consequence, Now or Never may soon become one of those pharmacy think pieces that generated analysis but failed to stimulate the required action.