A healthy balance
Community pharmacies are seen as healthcare clinics by the public but also need to be profitable in order to be viable. Is there a conflict between these two requirements, or can they operate in tandem?
You would be hard-pressed to think of retail business on the high street that has as much legal and ethical responsibility as a community pharmacy. Add the need for ensuring financial viability at the same time, and it starts to seem like one of the most challenging business plans imagineable.
As the industry’s independent regulator, the General Pharmaceutical Council (GPhC) has standards of conduct, ethics and performance that mention making patients the first concern, using professional judgement in the interests of patients and the public, and promote the importance of honesty and being trustworthy. All pharmacy staff are accountable for their decisions and actions, and the standards explain that professional judgement must not be affected by personal or organisational interests, incentives or targets.
So how do pharmacists balance their clinical responsibility with the need to make money? Can you be a successful business person and an exemplary healthcare practitioner at the same time?
Sanjay Ganvir, professional services director and superintendent pharmacist for Green Light Pharmacy, thinks the question is “a bit too binary” because “pharmacy’s most significant income source is the NHS, so it has to deliver what the NHS contract demands”.
Ganvir says the NHS constitution is clear. “By definition, to deliver on our commitments to the NHS constitution and our NHS contract is to deliver on our professional clinical obligations to our patients,” he explains, adding that he does not see delivering outstanding clinical care as the opposite of running an efficient business.
Kevin Cottrell agrees. He has worked in pharmacy for 30 years and is superintendent pharmacist at SG Court Pharmacy Group, overseeing 21 pharmacies in the south east of England. He does not see a gap between business and clinical responsibility: “If you are providing a good service and are commercially minded then you can satisfy both needs: the patient will feel like they had good service and you’ll make money,” he says.
For community pharmacist Adam Yates, the relationship between manager and healthcare professionals are not “linear extremities on a spectrum”. He believes you can be good at both at the same time by “being pragmatic” and focusing on “quality and effectiveness in an environment that uses resources efficiently”.
However, he also says clinical responsibility must always be “the foremost concern”, which, for example, “may mean a referral rather than a sale where appropriate”.
Often a sale with advice, or just advice, is not about profitability but about not being unnecessarily risk averse
“This distinction is essential because often a sale with advice, or just advice, is not about profitability but about not being unnecessarily risk averse,” he says.
Cottrell also sees the benefits of such micro-balances. “For example, a drug might be more expensive but better for a patient and what they want. This can be a commercial decision as well because it makes the patient happy and so they’ll come back. You have to balance out what you do — and what you don’t do, in some cases — with a commercial hat on.”
On the flip side, this can mean pharmacists feel compelled to stock or sell medicines and products that they do not believe are effective or suitable for that patient.
Yates says the organisation he works for decides “for the most part” what medicines are stocked and where they are displayed, and that this is not unusual. However, if he had autonomy over stocking the over-the-counter sales section of the pharmacy, he says he would steer away from “e-cigarettes, branded painkillers, cough mixtures that make wild claims, or herbal medicines”.
Sid Dajani, owner and pharmacist superintendent at Wainwrights Chemists (and a member of the Royal Pharmaceutical Society’s English Pharmacy Board), operates along similar lines, selling only health and wellbeing products, gift sets and a few homoeopathic lines which are asked for by patients, so that “when asked, we tell them the truth so they can make an informed choice”.
Being open to what the customer wants is also Green Light Pharmacy’s strategy. Ganvir describes it as a “patient-centred, co-created but also evidence-based approach to consultations” which involves staff having “dynamic” conversations with patients.
Nonetheless, he says this still sometimes results in customers wanting a product he feels is inappropriate — they do not stock homoeopathic items because “there is no robust evidence to support them” — or to use a product outside its licence, but he remains steadfast on his “duty to give the best advice and not compromise good clinical patient outcomes”.
To this end, he and his staff are always prepared to talk someone out of a sale if they believe a product is ineffective or unsuitable for that patient. “The public very much appreciate this, and it engenders a trust that subsequently results in a level of customer loyalty that is humbling,” Ganvir adds.
Yates, too, says that he “regularly” influences patients’ decisions to “improve their understanding about how they manage conditions with medicines in a more evidence-based, safe and cost-effective manner”. He says he has never sold a more expensive or branded medicine where a more cost-effective option exists, that he has never felt pressured by any organisation to do this.
I do not believe in selling medicines too cheaply because you devalue them and your time, and people think ‘is this stuff rubbish because it is so cheap?
However, when it comes to excessive discounting, Cottrell has a word of warning: “One of my pharmacists told me he had done a great deal on some loratadine at 50p per pack and was selling them on at £1.99 with a ‘buy one pack get one free’ offer. I pointed out that selling customers enough for a couple of months meant he would not see them for the rest of the season, which is not a good commercial decision. I do not believe in selling medicines too cheaply because you devalue them and your time, and people think ‘is this stuff rubbish because it is so cheap?’”
Recognising a demand for services is another way to address unmet clinical needs, and it can also increase revenue. But is the hard work worth the extra effort, and do you make the decision with your clinical or business head on?
Ganvir says that any additional services “have to be sustainable and financially viable”, which is why he will only introduce something new if he believes there is demand and “if it fits with our core value of being clinically focused”.
Ifti Khar, manager at Eye Pharmacy in Mirfield and Dewsbury, acknowledges the requirement to be both entrepreneur and clinician — a duality mirrored in the business’s role as a community pharmacy and optician offering full NHS and private optical and pharmacy services, with eye tests carried out by an optometrist on site.
Explaining the thinking behind this, Khar says: “We combined optical services with our offering because our business is pharmacy but we wanted to do something different. Traditionally, opticians do not have a high footfall but people come to a pharmacy regularly so we get more customers for both by linking the businesses in this way.”
This innovative model is not without its pressures, and Khar admits that he spends half a day a week just on paperwork but says “I try to do it outside pharmacy hours because when I’m working here, I’m working as a clinician”.
And, while it is the product and the service that generates revenue, it seems the temptation to perform a service, such as a medicines use review (MUR), in order to meet targets or generate additional revenue — rather than for meeting a clinical need for a patient — is not a modus operandi for most.
Yates says: “Although targets drive service provision I have never felt tempted to perform services that are unnecessary”.
Dajani explains he “would not dream of performing unnecessary services” and also “would not have time because of all the necessary services and everything else that needs doing that I can’t keep on top of”.
Cottrell says he never has either, and “would and have come down hard on anyone who I find has done this”, adding that he has “got a bit of an issue with targets because if you focus on them you miss the point. You can do MURs but then you ignore the people coming in with the prescriptions, and what does that do to your bottom line”?
But ten years on from the introduction of MURs as the first advanced service, Yates says he does not think that community pharmacists “have an excuse for not achieving 400 MURs a year, on the basis that the service is the most cost-effective vehicle to having a clinical input into the health and wellbeing of patients, optimising medicines use and reducing medicines waste”.
Cottrell adds that his business does set a budget at the start of the year but does not give financial incentives for achieving MURs because “it’s a day-to-day part of our business”.
And for Ganvir, framing the question as financial targets is missing the point. “If you asked a GP ‘is the quality and outcomes framework (QOF) about financial targets?’ they would say ‘no, it is about clinical outcomes’. Likewise to us it is about clinical targets. If we deliver excellent clinical outcomes, as set out in the community pharmacy contractual framework (CPCF), then the financial bit follows.”
Nonetheless, many pharmacists believe the pressure to make money and deliver services has increased since they first qualified.
“To make the same money [as in the past], you are running just to stand still. That’s where the pressure comes from,” says Cottrell. “We’re making less money but doing more to do so. When I first started in pharmacy we were doing 2,500 items a month, and the average now is 6,000, and rising. This is not sustainable as it stands, and now government wants to reduce the number of pharmacies.”
We’re making less money but doing more to do so
Sue Allen retired from community pharmacy three years ago, and for the past ten years of her working life was a locum in a variety of settings. She says that, although professional standards have improved enormously since she began her career in the community in the 1960s — thanks to the advent of consultation areas and the improved public profile of pharmacists as medical professionals — she found the downside was that “money had to be saved on staff and space, and huge increases in prescription volume are not being met by increased numbers of staff to deal with the workload, nor with provision of larger dispensaries”.
A squeeze on staff numbers also caused concern for John (not his real name), who spent the past 20 years of his working life, before retirement, in community pharmacy. He says: “There was no direct pressure to sell this or that or [offer a particular] service, but there was increased pressure in terms of the amount of work that was expected, yet the number of staff available to deal with that was decreasing.
“This led to situations where the pharmacist could be alone in the shop over break times, and in the 100-hour pharmacies early in the morning and late at night you could be by yourself. This was extremely dangerous from a security point of view, and also you could not give the proper service to customers who came in. It often was impossible to do the right thing — I thought, at times, it was stopping me meeting certain legal requirements of being a pharmacist.”
Being a community pharmacist is not supposed to be a walk in the park — it is essentially about problem solving all day every day
Yates, on the other hand, who qualified under the new CPCF, believes that, although pressure may have mounted through the number of services that can be delivered effectively and simultaneously, he enjoys the challenges. “Being a community pharmacist is not supposed to be a walk in the park. It is essentially about problem solving all day every day. I thrive in such an environment and believe that pressure can be managed and problems solved,” he says.
Ganvir can see both sides: “No one would say it is easier now than in the past — but I did qualify a long time ago. All of us need to accept the economic reality of the pressures on the healthcare system and the NHS, but for innovators there are great opportunities. This is happening on our watch, we need to step up to the plate, and perhaps this is the best time in generations to be a pharmacist.”
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2015.20200319
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