Third Report - Pharmacy

There is clearly something wrong if the funding that pharmacies receive from the NHS does not cover medicine costs, given their core function of dispensing medicines. The Community Pharmacy Contractual Framework is evidently not fit for purpose. It is overly complex and has contributed to the financial pressures that pharmacies are facing. Given the scale and timetable of the Government’s stated ambitions for the changing role of community pharmacy, the ways in which pharmacies are funded requires reform urgently to ensure they have the funding to deliver what will be expected of them.

We recommend that the Community Pharmacy Contractual Framework (CPCF) is completely overhauled, in close consultation with the community pharmacy sector. Any new framework must: a) close the gap in funding that community pharmacy has experienced over the course of the current CPCF; b) focus on reducing complexity and ensure pharmacy owners can clearly understand and predict their cash flow, including de-risking the purchasing price of medicines; c) ensure funding is explicitly available for both dispensing services and clinical services, to avoid the current situation where one activity pays for another, to the detriment of both d) include the capacity for flexibility in the event of increased demand, greater activity or inflationary pressures, for example through indexation. (Paragraph 20) Medicine Shortages

Tackling medicine shortages is another vital component in securing the ability of pharmacy to meet its future potential. Medicine shortages cannot be ignored and left to become the norm. The wider implications of medicine shortages for the long- term potential of community pharmacy to take on more clinical work are deeply concerning. The time pharmacy teams are having to spend dealing with shortages is time that they could be spending with patients, and indeed will need to if the clinical role of pharmacists is expanded. Continuing shortages, serious or otherwise, run the risk of eroding public confidence in community pharmacy, with patients frustrated about the service they receive.

It is also especially worrying that shortages are resulting in patients being directed back into general practice. There is a serious risk that any capacity that general practice gains, through services like Pharmacy First, will be negated by the time spent re-issuing prescriptions as a result of shortages, thus undermining this initiative.

We recommend that the Government reviews the effectiveness of Serious Shortage Protocols, with a focus on their timing and their administrative burden. (Paragraph 49) 44 Pharmacy

We recommend that regulations are updated within three months to allow pharmacists in community settings to make dose and formulation substitutions for out-of-stock items, subject to the safeguards set out in the Royal Pharmaceutical Society’s Medicines Shortage Policy.

We believe that allowing generic substitution would be an important way of reducing the need for patients to return to their GP for out-of-stock medication. We further recommend the introduction of generic substitution, which should follow a government consultation focusing on how best this policy could be implemented to ensure patient safety and avoid the potential for unintended impacts on the supply chain.

In their response to this report, the Government should set out what impact it believes National Patient Safety Alerts have on private prescribing and what scrutiny and enforcement measures are in place to ensure private prescribers adhere to these alerts.

The global supply chain for medicines is complex, with a range of different actors involved in getting medicines from the raw materials to the manufacturer to the patient. The Government needs a clearer understanding and overview of the whole process, and the risks at each stage. If the Government already has that clarity, that should be communicated to Parliament. Only then can weaknesses in the chain, their causes, and how to tackle them be truly established so that the Government can get on top of this growing issue and provide the necessary solutions.

The Government should commission an independent review of the medicines supply chain. Given the impact that shortages are having, this should be commissioned as soon as possible and completed within 6 months of starting. The review should assess, and suggest ways of improving, the resilience of the supply chain, the performance and role of the MHRA and the impact of prices paid for medicines and community pharmacy reimbursement mechanisms. We recommend a particular focus on the availability and use of generic medicines, though the review should not be limited to these. (Paragraph 64) Extending pharmacy services

We have been encouraged to hear the enthusiasm within the pharmacy profession to deliver more patient facing care. However, the undoubted potential for pharmacy to improve access to health care, crucially including immunisations, and reduce pressure on general practice and other areas of the health system can only be realised with the right support and the right investment of public funding.

We recommend that the Government and NHS England publish a long-term vision for the further development of clinical services in community pharmacy settings within one year. This vision should: a) include consideration of examples of success within locally commissioned services, and how these could be offered across England b) build on the seven health conditions covered by Pharmacy First and the delivery of blood pressure and oral contraception services by pharmacists; Pharmacy 45 c) commit to expanding the role of pharmacists in the management of long-term conditions d) commit to expanding the role of pharmacists in carrying out medication reviews and supporting medicine adherence; and e) be supported by a plan setting out timeframes for the delivery of new services and commitments to the allocation of realistic levels of funding to any expansion of services.

In the shorter term, and in light of the large body of evidence and long-running calls for these services to be offered in community pharmacy settings, we recommend that NHS England commissions community pharmacies to provide the HIV-prevention medication PrEP and all routine and seasonal immunisations for adults and children.

It is clear that pharmacists are already struggling to find the time they need for consultations with patients in often busy community pharmacy environments with competing priorities, despite their ambition to do more. Future service expansion must be conscious of the capacity of pharmacists to deliver both existing services, and any planned expansions.

While hub and spoke arrangements may be beneficial to some pharmacies, we do not believe this is a ‘silver bullet’ in terms of efficiencies. We urge the Government not to assume that hub and spoke alone will deliver the extra capacity pharmacists clearly need to deliver clinical services. We note the Government’s response to their consultation and intention to proceed with plans to allow hub and spoke systems to be set up across different legal entities, but caution against encouraging, or even mandating, more widespread implementation.

Public concerns about being referred back to the GP if they use community pharmacy to access healthcare should ring alarm bells for the Government. It is encouraging that this does not seem to be the experience within Pharmacy First, but we know that medicine shortages are driving people back to their GPs. We are concerned that this reinforces the public concerns.

As well as addressing medicine shortages and broadening pharmacists’ ability to offer alternatives, to support public confidence and education, the Government should commit to the ongoing promotion of Pharmacy First beyond what has already been announced.

Community pharmacies offering clinical services must have private, comfortable spaces in which to see patients. We acknowledge the minister’s comments around pharmacies being private businesses, but they are ultimately expected to provide NHS services. As the expanding availability of clinical services in pharmacy settings is encouraged, we believe a more balanced approach is needed to support smaller, particularly independent, pharmacies to keep up with larger ones and have the resources to create the appropriate conditions in which to provide the new services that the Government and the public want to see. (Paragraph 105) 46 Pharmacy

We recommend the creation of a new “Establishment Payment” to be paid to eligible community pharmacies to support the development of consultation spaces for patients. This funding should be targeted at pharmacies that are the most reliant on NHS work as their main source of income and could be linked to a commitment to provide an agreed level of NHS service.

To avoid patients continuing to use GPs for support that could be offered in a community pharmacy setting because of concerns about the affordability of over-the- counter medication, we recommend that such medication is free for people on low incomes, as part of the Pharmacy First scheme.

When responding to this report, we ask that the Government sets out what progress has been made on rolling out the full digital product for the documentation of Pharmacy First consultations, including the percentage of community pharmacies that have fully functioning and interoperable read/write access to patient records.

We recommend that the ongoing evaluation of Pharmacy First includes an assessment of the extent to which pharmacy and general practice digital systems are enabling the necessary data sharing to protect patient safety and ensure continuity of care.

There are clearly benefits to be found from using automation and technology particularly within hospital medicines management. These benefits could unlock gains in productivity, improve patient safety and free up pharmacist time to work more directly with patients. There are pockets of excellent practice across the NHS, but, outside of formal programmes like the Global Digital Exemplar programme, this is often driven by innovation from key individuals in pharmacy departments and can lack more senior support. To ensure equal access to high quality care, and in the context of the ongoing New Hospitals Programme, NHS England needs to have a more strategic view for how medicines are managed in hospitals across the country.

We recommend that an independent review is commissioned to explore hospital medicines management, to report within one year. The review should make recommendations, particularly around how the potential of automation and technological systems like connected medication management could be realised and how learning from Global Digital Exemplars can be built upon in Trusts across England. (Paragraph 131) Pharmacy Workforce

The lack of access to placements, supervisors and adequate financial support is a serious challenge, which could undermine efforts to meet the pharmacy targets set out in the NHS Long Term Workforce Plan. If those ambitions are to be met, there needs to be a greater focus on the availability and quality of the necessary placements.

We recommend that the list of healthcare professionals able to access the Learning Support Fund is updated to include pharmacists and technicians. (Paragraph 140) Pharmacy 47

The criteria connected to Additional Roles Reimbursement Scheme (ARRS) funding should be reviewed within 3 months to understand whether any additional flexibility could reduce the drain of community pharmacists into primary care networks. The Government should write to us with the outcome of this review.

Greater planning and forward thinking continues to be needed around the full pharmacy workforce, accounting for changing roles in the community, increasing demand in hospitals and supporting ICBs to build “one pharmacy workforce” that can be deployed across the full range of pharmacy services within health and social care. As 2026 approaches, when all newly qualified pharmacists will also be independent prescribers, this will become ever more urgent.

We reiterate that an integrated and funded workforce plan for pharmacy must be developed and laid before Parliament within 12 months. This should focus upon delivery of the targets set out in the NHS Long Term Workforce Plan. The pharmacy specific plan must: a) ensure that all pharmacists have adequate access to supervision, training, and protected learning time, along with clear structures for professional career development, including to support those who wish to complete independent prescribing courses b) consider that from 2026 all newly qualified pharmacists will be independent prescribers and ensure that these graduates are given protected learning time, adequate supervision, career development opportunities and that there are commissioned services available so they regularly make use of their IP qualification. c) set out a clear vision for the further development of the role of pharmacy technician, and action that will be taken to deliver it.

We further recommend that any workforce planning, be it at a national or ICB level, should ensure the appropriate and safe and mix of skills in all settings, including hospital wards as highlighted by Dr James Davies of the Royal Pharmaceutical Society. This should include consideration of the need for more than one pharmacist per community pharmacy in relation to the delivery of initiatives such as Pharmacy First. (Paragraph 174) 48 Pharmacy