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Community pharmacy

Dispensing: it’s time to let it go

Community pharmacists must adapt their role to new market realities if they are to survive.

According to suggestions from the latest Nuffield Trust report

Source: Shutterstock.com

If the aspirations of pharmacy fulfilling a clinical role integral to public healthcare is ever to be realised, community pharmacists must shift their focus away from dispensing and towards NHS service provision.

The new report ‘Now more than ever’ — authored by Judith Smith, director of policy, and colleagues from the Nuffield Trust — assessed the short-term headway made in implementing the original recommendations of the Royal Pharmaceutical Society’s 2013 report ‘Now or never’.

The original 2013 report outlined the findings of the Royal Pharmaceutical Society —‘Future models of care commission’, chaired by Smith. The commission’s work could be interpreted as the latest in a long line of reports and policy documents — including the 1986 ‘Nuffield report: a signpost for pharmacy’ and the 2000 NHS national plan document ‘Pharmacy in the future’ — looking for pharmacy to fulfil its potential and secure the future of pharmacy in the face of transformative technology.

It is clear that, at some point in the near future, the current system of dispensing will be deemed unsustainable and pharmacy will need to reform to this brave new world.

Talking about revolution

If there is to be widespread reform by 2020, community pharmacy requires a revolution rather than evolution. Any revolution in community pharmacy is likely to be precipitated by a massive divestment in prescription dispensing in order to release money to help fund growth of NHS integrated care organisations. Indeed, the UK government may reduce the availability of NHS fees guaranteed to pharmacists (as happened with opticians and dentists in the past) so that more money is available for spending on the practice-based primary care team.

With substantial competition from big players and local practices keen to compete for the same work, the incomes of many community pharmacists will shrink rapidly

With the use of new technologies, dispensing in the community could soon replicate the dispensing systems used in hospitals. Indeed, policymakers are pushing for the replication of hospital dispensing arrangements in the community and have been quietly preparing for factory-type dispensing pharmacy outlets.

As the role of commissioning pharmacy services passes down to clinical commissioning groups (CCGs — NHS organisations that organise the delivery of NHS services in England), the cheapest supplier could be contracted to dispense all medicines in a locality, with patients receiving delivery of their drugs by mail or courier. Many community pharmacies would then shut. The cost of dispensing prescriptions to the community to the NHS could probably be more than halved, quite easily.

The money saved by reducing NHS dispensing costs could fund a smaller number of solo pharmacists to work on initiatives in patient care, with the work going to those who sell their services the best.

Alternatively, pharmacy chains, consortia of pharmacists and other interested healthcare providers could compete to provide medicine optimisation services to local CCGs. The remaining savings could then be invested in newly formed integrated care organisations. In such a world, there would be little need for a national pharmacy contract or independent contractors providing dispensing and related services.

Brave new world

A switch to service provision is therefore an unavoidable future for pharmacy. The development of medicines use reviews (MURs) and other forms of medicines reviews are closely akin to the US system of drug utilisation reviews. The UK system of MURs has been criticised for being conducted without full patient records. Indeed, for pharmacists to maximise their performance at offering medicine services they must be integrated fully into the NHS.

The implications for pharmacy practice are substantial. For independent community pharmacists, incomes will probably become reliant on the ability to provide services to patients rather than dispensing medicines

Therefore, the RPS Committee’s vision of a NHS led by integrated care organisations would better suit the provision of MURs and related activities than the existing system of isolated, community-based retail pharmacies.

The implications for pharmacy practice are substantial. For independent community pharmacists, incomes will probably become reliant on the ability to provide services to patients rather than dispensing medicines. With substantial competition from big players and local practices keen to compete for the same work, the incomes of many community pharmacists will shrink rapidly.

Multiples are likely to suffer as integrated care organisations take dispensing in-house or non-pharmacy health care providers establish dispensing businesses as adjuncts to other NHS contracting activities.

Can-do attitude

Policymakers, general practitioners and NHS commissioners need to hear a consistent “can-do” message from pharmacists about how pharmacy can help solve many of the challenges in patient care facing the NHS patient. The national community pharmacy contract, made between pharmacy contractors and the Department of Health, should be changed and new payment mechanisms should be introduced to enable pharmacists to assume a wider care-giving role.

Community pharmacy is in need of strong leaders with a vision that can unite internal divisions and persuade those resisting change to deliver the promise of greater involvement in patient care

Funding models must also be reorganised at a local level. Pharmacists must be relentless in making the case locally for their vital contribution to patient care.

If this does not happen, community pharmacy risks being overtaken by the expansion of technology-driven dispensing, and in pharmacy services being delivered by new NHS organisations.

Community pharmacy is in need of strong leaders with a vision that can unite internal divisions and persuade those resisting change to deliver the promise of greater involvement in patient care.

The strategy the report endorses can be seen as a “lifeboat” in which community pharmacists will need to jump into by 2020, when changes to the national contract and the introduction of localised integrated care will undermine the traditional model of a local retail pharmacy for local practice patients.

The current funding arrangements for pharmacy and model of care are unsustainable. Pharmacy should be empowered to let go of the dispensing function and seizes the opportunities on offer. If pharmacy fails to rise to this challenge, its role in the community beyond 2020 looks bleak.

 

Darrin Baines is professor in health economics at the University of Coventry

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2015.20067705

Readers' comments (7)

  • It may well be that the NHS will decide to do most large scale dispensing in house with prescriptions delivered by couriers or post a few days later. This could make the bulk of pharmacies unsustainable. The only solution may be to make pharmacy a stream of medicine and instead of throwing thousands of pharmacists on the scrapheap the NHS could start in work training for all pharmacists as physician assistants to help relieve the huge shortage of GPs. Giving savings on dispensing and savings on medical treatment and diagnosis along the way.

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  • Interesting suggestion Gordon. In essence that is the same as saying the profession of pharmacy should be phased out completely through the retraining of pharmacists as physician assistants. I'm not sure many would agree with that.

    The challenge that the profession faces is identifying which unique skills possessed by pharmacists are required in the future. Training of pharmacists should focus on enhancing these and proving their value to patients and the health service. As both you and Darrin have highlighted, dispensing can be relatively easily automated. Fighting to retain this under the local pharmacist's control has echoes of local ironsmiths calling for legislation to protect their livelihoods in the face of industrialisation.

    Perhaps pharmacists can learn from GPs. The reason GPs still retain such a major influence over the NHS is that you can't easily automate the diagnosis of illness and the prescribing of appropriate treatment. Medicine is both a science and an art. This is not to disparage other medical professionals but the reality is that GPs are viewed as the expert "generalists" when it comes to the diagnosis of illness. Technology has yet to make obsolete the role of GPs and other medical doctors. If anything, it has enhanced their position and made patients more reliant on them.

    Ask yourself what it is that pharmacists do - or could do - that computers (or other professionals) would not be able to do. If the answer is, "Nothing!" then your suggestion is valid. Darrin and a lot of pharmacists would disagree.

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  • It worries me that some pharmacists seem keen to "let go" the dispensing role. Other professions rarely let go of anything. The key to success seems to be to keep control of existing roles, in our case retaining the overall responsibility for dispensing with SOPs that ensure the involvement of a pharmacist where necessary and at the same time develop new roles. With this model we would retain the responsibility for a safe, efficient distribution of all medicines while developing additional functions.

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  • Merlin and Martin it is not that pharmacists want to lose any roles in dispensing but as pharmacists do not own the international chains or the NHS the role may be removed by either of these organisations. The question then is how to save all the pharmacists and the heavy investment in them, for the NHS and thus the suggestion that we get involved in prescribing & diagnosis, get access to medical records, map of medicine etc and help from the RPS & NHS to achieve these goals IF dispensing is taken away from us.

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  • There's an elephant in the room. Darrin has looked it straight in the eyes and addressed it. That much is demonstrated by the number of comments that this article has elicited.

    Undoubtedly, at the broadest level, his summary is correct. However, there are a couple of points I'd disagree with.

    To process a large amount of dispensing and accuracy checking activity in a safe, robust and scalable way, it will be necessary to use high performance, robust and proven technology. Such technology, redundancy and the necessary people and logistics infrastructure to use it to deliver a safe and compliant service of what is a mission critical activity costs money.

    Either the NHS needs to make a significant investment to make that vision a reality (unlikely) or they will need to convince private enterprises (chiefly the vertically integrated chains, but also potentially new entrants to the market including overseas pharmacy companies and the technology manufacturers) that it's worth making that investment. A wholesale (sorry for the pun) reduction in the dispensing fee (or even the hint of one occurring) is unlikely to achieve that.

    In essence, service income will need to be 'guaranteed' for a period across a certain capacity to fuel progress. The PSNC will need to adopt an open mind and engage with KOLs across the contractor space to develop and deliver a negotiation strategy that achieves this.

    In order to drive progress and ensure equity of access for all contractors, it's essential that Government moves to reform section 10 of the Medicines Act. The current restriction that prevents independent pharmacies from utilising 3rd party hub and spoke dispensing services provided by a pharmacy not under the same ownership provides the vertically integrated chains with a huge amount of commercial advantage and is not in the best interests of patients. This will be demonstrable once the enterprise level hub and spoke centres used by Boots and Lloyds come online…

    Finally, I'm a firm believer in the value that community pharmacy has for patients. I think that any move that puts the accessibility of the pharmacy (and the pharmacist) at risk will elicit protest from the population that relays upon the service , chiefly the elderly - which is a group that is growing in size year on year.

    Centralised dispensing centres will not have the responsiveness to deal with acute prescriptions or the ability to handle dispensing of quantities that are not aligned with full patient packs. A properly resourced community pharmacy service will be needed to handle these.

    Centralised dispensing centres will not be geared up to provide tailored advice and clinical pharmaceutical care to patients face-to-face. A properly resourced community pharmacy service will be needed to handle this.

    Automated centralised dispensing centres will not be able to carry out clinical or legal approvals of incoming prescriptions. A properly resourced community pharmacy service will be needed to handle these.

    I see the community pharmacy service as being a key part of the logistical chain from manufacturer to patient. Consumers have demonstrated the value they find in 'click and collect' facilitated by the evolution of the web and advancements in logistics technology and networks. It's time for pharmacy to make that step change to build capacity, rationalise costs and improve patient safety.

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  • Mukesh Patel

    Pharmacy face to face contact has the capacity and capability to tailor clinical advice promptly with ease and build patient confidence.Many customers regard the pharmacist as their personal doctor.Robotic dispensing and delivery by couriers will loose the regular face to face contact.

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  • If Pharmacists are redundant, in this brave new world, why is the government frequently telling the public to "Go ask your Pharmacist"?
    To ask their Pharmacist they will need one they can A,access, b, know, c, trust. as many of them do now. Hence Pharmacist being one of the most trusted professions in every annual poll.
    Yes we may not be so directly involved in the mechanics of dispensing. (They have taken all the fun out of real dispensing, like actually making something).
    But and it is a big BUT patients do rely on us for reliable advice, for all sorts of things. How often have you been told "I don't want to trouble the Doctor" or "The Doctor doesn't have the time or doesn't give me the chance to ask"
    There is and will be a need for the "Front Line" local pharmacist. How they are funded may be the critical question.

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