Tim Clement-Jones

All Party Group debates the future of pharmacy

I recently spoke on a Panel at the All Party Pharmacy Group on 11^th September about the the Future of Pharmacy.

Here is what I said: 

Pharmacy in Britain is an incredible resource. I am a fan of pharmacy. It is often able to respond quickly and effectively to the consumer/customer/patient and to the right incentives.

It's called community pharmacy and the  best pharmacies really are part of the community.

Some 10% of the NHS budget, when considering drug costs is channeled through community pharmacists

In the UK there are over 47,0000 registered pharmacists and over 21,800 pharmacy technicians. Of which there were 38,867 registered pharmacists and 18,165 pharmacy technicians in England last year.

The NHS Business Services Authority reports show that there were 11,236 community pharmacies in England at 31 March 2012.

That means there has been an increase from 9,500 of 15.3 per cent since 2002-03.

This compares to 10,000 GP general practices in England.

Of these 11,236, 61% are owned by multiples, that is they are in a chain of five or more.

They dispensed some 885.0 million items annually across England compared to 566.3 million in 2002/3.

So we have had huge growth in number of pharmacies over the past few years particularly as a result of the scheme to encourage new pharmacies that offer 100 hours a week to open.

That growth won’t continue.

 Student Numbers

As former chair of the School of Pharmacy I have a strong interest in this area.

The Centre for Work Force Intelligence (CfWI) has now published a report on pharmacy workforce and student numbers which shows that by 2040 there will be an over supply of pharmacists of between 11,000 and 19,000. They recommend a staged approach to managing these numbers.

There has been a huge increase in graduate numbers with the expansion of schools of pharmacy in England from 12 to 21 in between 1999 and 2009,  with several more opening or due to open.

This is not just due to new school of pharmacy opening, but also an expansion in numbers by the established schools. For example, several universities have a campus in Malaysia which swells their final year cohort. For example, Nottingham have around 300 students there.

This means too many graduates coming through the system from both the new and established schools. The number of  undergraduates at any one time has gone from 4200 in 1999 to over 9800 in 2009. In the 2011/12 academic year there were 10,951 pharmacy students and 3,104 entered MPharm programmes in England .

This not only places pressure on clinical placements and academic resource but on preregistration places in pharmacies These are wholly within the control of employers –despite the investment made by the DoH – and are becoming much more scarce. NHS pre-registration training positions are falling too.

So we have a major issue now with an over supply of graduates from our schools of Pharmacy.

How do we ensure that we have the right number? How do we ensure that the education they undertake and the debts that they incur gives them the clear prospect of employment

This is under debate. BiS and DoH are in discussion about how numbers can be regulated with HEFCE the GPhC the RPS and the schools of pharmacy. At the request of the government, The Higher Education Funding Council for England (HEFCE) and Health Education England (HEE) are consulting on the supply of pharmacy graduates in England.

The consultation started on 2nd September, 2013 and will run until the 15th November, 2013.The HEFCE/HEE joint consultation proposes three options:

•  To continue to allow the market to determine the number of pharmacy graduates
• To introduce an intake control at each university for entrants to MPharm pharmacy programmes
•  To create a break-point during study which enables some students to graduate with a Bachelor of Science degree and others to progress through further study to qualify as registered pharmacists

Which option do we chose given that the market seems not to be delivering an acceptable solution?

Controlling the entry numbers is the medical nursing and dentistry option. But who is going to do that and how?

Neither HEFCE nor GPhC appear to want to do this.

It might even  be preferable rather than spreading pain across all schools to licence certain schools to deliver the MPharm and or the Bsc on the basis of quality. Could the GPhC take this on?

Even if a cap on student numbers were to be implemented tomorrow, there will still be a 5-6 year lag in the system.

As regards the actual content of the MPharm we have had an increasingly well qualified graduate population especially over the last 10 years.

The MPharm coursescould be even better.

A review conducted for Medical Education England proposed an integrated 5 year course including a much greater clinical content with a strong contribution from employers as the 5 years would include 2 practice placements.

Joint sign off by the HEI and the employer would be needed to graduate.

 Past Initiatives

 Currently however it is arguable they are over educated for what they do.

We need to use our pharmacists to better clinical effect particularly in primary care.

This is not to say that successive governments and the pharmacists themselves have lacked ambition .

Many of the initiatives taken involving pharmacy don’t get buy in from GP’s. For example the latest statistics available (28 June 2013) show that 90% of pharmacists can receive electronic prescriptions but only 10% of GP’s are in a position to prescribe this way.

Pharmacists have invested money in consulting rooms but many have yet to see a return.

 Whether initiatives have been effective seems to depend on whether a service is centrally mandated or at local discretion.

Contrast centrally funded Advanced Services eg New Medicines  Services and Medicines Use Reviews  with Enhanced Services such as Obesity initiatives locally commissioned by CCGs and formerly by PCTs.

MUR’s were introduced in 2005 under the new contractual arrangement for pharmacy under the Labour Government-and far better in their impact than the GP’s equivalent -are conducted by community pharmacies. Compared to 2.1 million in 2011/12.

A total of 2.4 million Medicines Use Reviews (MUR) were conducted by community pharmacy contractors in England in 2011-12, compared to 2.1 million in 2010-11, an increase of 325,524 (15.4 per cent).

Enhanced services by contrast have been a great aspiration but how successful have they really been?

 Local enhanced services –which are at the discretion of PCT’s/CCG’s  have actually decreased. The number of local enhanced services provided by community pharmacies in 2011-12 decreased by 1,679 (5.4 per cent) to 29,283 since 2010-11

Of the twenty services commissioned by PCTs the most commonly commissioned services in 2011-12 were Stop Smoking (19.2 per cent), Supervised Administration (19.1 per cent), Minor Ailment Scheme (12.1 per cent) and Patient Group Direction (11.9 per cent).

So we need to be very careful about we fund and configure services for the future.

The Future

As AT Kearney’s recent study shows however the winds of change are blowing.

What it calls the five forces for change are on the way which will inevitably mean closure of significant numbers of pharmacies.

• Squeeze on healthcare budgets
• Intensifying competition
• Transformation of the supply chain
• Emergence of new alternative channels
• Demand for convenience and expertise

Kearney says that in the face of these forces pharmacies can build on their trusting relationships with customers to become a front line point of care.

Unless we invest wisely in community pharmacy now, and build intelligently on the heritage of NHS community pharmacy and GP practice and if too much future investment goes into bigger secondary institutions rather than truly local facilities we will not gain the advantages of the new technologies now being introduced in medicine  and  IT.

We need to recognize the people want much more control over their own health.  They want information and professional advice and support  to be able to make choices. The classic change from Klein’s Church to Garage model! How do we best deliver what is called self care?

Change is under way in the pharmacy already. The future is robots on the one hand for dispensing and diagnostics and other skilled preventive and medicines management roles on the other.

The fact is that with reduced budgets and generics pharmacists will have to focus on services rather than products.

Do we need in effect a new breed of apothecaries as suggested in a recent paper with a much stronger clinical role going beyond diagnostics and health checks?

In the end this will be good for patients and the pharmacy profession

Our current primary care system is not designed to deal effectively with public health issues. We need much greater emphasis on prevention. Despite the experience of Enhanced Services we need major action on Smoking, diabetes, hypertension.

We need much better ways too of dealing with minor ailments.

Then there is the management of long term conditions allied to supporting independent living at home. The demographics mean that more older people living longer. 50% of the population will be over 50 by 2024.

With scarce resource Medication Therapy Management (MTM) will become even more important. We need to find effective ways of  supporting NICE’s Guidelines on Adherence

Research by Prof Rob Horne and Professor Nick Barber at the School of Pharmacy, UCL shows that 50% of medicines not being used to best effect.

Some regarded the MUR’s as little more than a chat.

So the New Medicines Service was introduced as a result of this UCL School of Pharmacy research in 2011 to help support patient taking a new medicine and involved pharmacists phoning patients a week after starting an new medicine to check that they are adherent.

Pharmacy could contribute greatly to all these issues as the so called Third Pillar of Health care.

The new RPS Faculty has the potential to be an important development for the profession. The RPS launched it earlier this year, and it is in essence an accreditation structure for the profession, allowing those in practice to develop their clinical skills and become recognized for their achievements.

This recognises that Propper and more clinical use of pharmacists could lead to a massive reduction in hospital admissions and the productivity savings the NHS desperately needs but seems unlikely to achieve.

For much of this pharmacists will need appropriate access to health records.

Much will depend on the ability to collaborate with GP’s.

Why does it seem that GP’s are so reluctant?  Do GP’s want to be want to be the gateway for everything  even for preventive health care, self care , minor ailments and medicines management for which pharmacists are ideally suited?

Pharmacists need to operate more more flexibility too.

The greater use of technicians and more flexible contracts instead of locums.

How about new pharmacist staffed Community Health Centres.

Maybe pharmacists should be given a more explicit out of hours role.

This all leads to the question of how much professional freedom we give to the pharmacists.

My view is that the pharmacist of the future with the developments underway in pharmacy education mean that pharmacists will be well able to undertake much more clinical responsibility and we must encourage it. I hope this will be in cooperation with GP’s.They crucially need to move with times too.

There are some positive signs here as I see that the head of the dispensing doctors association Richard West is very positive about the role that pharmacists can play in reducing GP workloads.

 

 

 

 

 

 

 

 

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by Tim Clement-Jones