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How many community pharmacies are too many? Are there too many now?

It is time for a public debate on community pharmacy numbers, according to England’s chief pharmaceutical officer. Dawn Connelly gathers some views on the issues involved

By Dawn Connelly

It is time for a public debate on community pharmacy numbers, according to England’s chief pharmaceutical officer. Dawn Connelly gathers some views on the issues involved

Does England have too many pharmacies? This is a question that sparked much debate on Twitter following comments made by the country’s chief pharmaceutical officer Keith Ridge at an Inside Government event on the future of community pharmacies, held in London last week.

The number of pharmacies in England has increased steeply since exemptions to the control-of-entry test were introduced in April 2005. Last year (31 March 2012), the number of pharmacies stood at 11,236, an increase of 285 compared with the same date in 2011. The number of 100-hour pharmacies increased from 689 to 888 over the same period, and distance-selling pharmacies increased from 122 to 176 (see Table).

 

Pharmacy numbers over the past decade

Year Number of pharmacies (n)
Independent contractors n (%)
Multiple pharmacies n (%) 100-hour pharmacies n (%)
Distance-selling pharmacies n (%)
2002–039,748    
2003–04
9,759
    
2004–05
9,736
    
2005–06
9,872
    
2006–07
10,133
4,169 (41.1)
5,964 (58.9)  
2007–08
10,2914,025 (39.1) 6,266 (60.9)
  
2008–09
10,475 4,019 (38.4)6,456 (61.6)
450 (4.3)
56 (0.5)
2009–10
10,691 4,131 (38.6)
6,560 (61.4)
535 (5.0)
76 (0.7)
2010–11
10,951 4,221 (38.5)
6,730 (61.5)
689 (6.3)
122 (1.1)
2011–12
 11,2364,346 (38.7)
6,890 (61.3)
888 (7.9)
176 (1.6)
Source: Health and Social Care Information Centre

 

Although Dr Ridge hopes the pharmaceutical needs assessment process now offers a more rational approach to the distribution of pharmacies in England, his view is that the current size of the network does not need to be maintained. In fact, some say there are 3,000 too many pharmacies already, he told participants at the meeting. “[This] is a debate which I think we have to have. A time of austerity is probably the right time but also a time when technology is obviously going to deliver much more. We have to have a public debate about that and that’s not going to be easy.”

This is not the only time the issue of pharmacy numbers has been raised recently. In September 2012, a report from business consultants AT Kearney suggested that as many as 2,000 independent pharmacies could close by 2015 because of a number of factors, including a squeeze on healthcare budgets, intensifying competition, transformation of the supply chain, emergence of new alternative channels, and demand for convenience and expertise.

The importance of ensuring the right balance between multiples and independents was emphasised by Dr Ridge. Sufficient pharmacies of high quality need to be maintained to support local communities, including the provision of public health interventions, and sufficient diversity of pharmacies, too, he said. “How that transition is managed is clearly critical. But it is inevitable, and I suspect when my children are my age the need to go to physical premises known as a community pharmacy will be much less.”

Local and available

Howard Duff, the Royal Pharmaceutical Society’s director for England, who chaired the event, told The Journal that he is not surprised commissioners are looking at pharmacy numbers given the savings in practice payments that would come from having a smaller network. However, he pointed out that being local and available are two crucial elements of community pharmacists’ role.

Jonathan Mason, clinical adviser for medicines at NHS England (London region), also spoke at the meeting. Afterwards, he told The Journal he agreed with the idea that the pharmacy network needs to shrink. “There are too many pharmacies, and there are concentrations of pharmacies in the wrong places,” he said.

“It is probably a bigger issue in large cities, but there are issues in smaller towns, as well. There are clusters of pharmacies around health centres — this is partly due to the old system, pre-control of entry, when contractors could leapfrog one another, so we ended up with several pharmacies on the same road, and partly due to the 100-hour exemption that enabled people to open unnecessary pharmacies, often in inadequate premises.”

He suggested that now could be the time for small and large multiples that have several branches within the same town to consolidate those contracts into larger, better premises.

“The problem is that pharmacies with an NHS contract are paid a variety of allowances but, while they are funded by the NHS, commissioners have had very little say in controlling numbers and locations of pharmacies,” Mr Mason added.

Chief executive of the National Pharmacy Association Mike Holden, who joined the subsequent Twitter debate, told The Journal that a view on what is the right number of pharmacies can only be formed once there is clarity on the Government’s strategy for community pharmacy’s role in health and well- being services.

“The number of pharmacies that are needed will depend on what services commissioners want pharmacists to provide and where they want patients and the public to access those services,” he argued.

He also warned that allowing distance-selling pharmacies to continue to be exempt from the market entry test could undermine the existing pharmacy infrastructure if they bypass the current patient-healthcare professional interaction. Provision of health services within the NHS should be planned as it is for other providers — that is what a pharmaceutical needs assessment should deliver, said Mr Holden.

Chief executive of the Pharmaceutical Services Negotiating Committee Sue Sharpe told The Journal she is not surprised that, given the scale of the financial challenges the NHS is currently grappling with, commissioners are looking at all costs across the whole health service.

“If community pharmacies focus solely on the dispensing service then the value we deliver will become increasingly difficult to justify when cheaper remote or warehouse operations could be considered.

“However, if we can develop the community pharmacy service to allow pharmacies to take ownership of areas such as public health improvement, medicines optimisation and management of long-term conditions, then pharmacies will be supplying medicines while, at the same time, helping patients to gain the maximum benefit from those medicines and improving the health of the nation. I believe that brings real benefits for the health service and gives us a compelling case for maintaining the current accessible network,” she said.

Separating supply and services

Automation of medicines supply, and separation of supply and services, is part of the debate. Dr Ridge believes that large scale automation of dispensing and medicines supply is inevitable. Eventually, he suggested, it will be on the same scale as that which currently exists in the US, where 10 warehouses serve 60 million people, roughly equivalent to the size of the UK population.

Mr Mason is more cautious. He suggested a mixed supply system, including some physical pharmacy premises (with hub-and-spoke dispensing systems making greater use of automation), greater use of online services (the “Amazon” model), greater use of homecare services and manufacturers supplying direct to patients. Alongside this, he said, there would be a need for pharmacists, working as part of an integrated primary care team, to support patients to help them get the best from their medicines.

However, Mr Holden is adamant that separating supply from services would be the wrong thing for patients, the taxpayer and the profession. “There is an opportunity to interact and potentially intervene when supplying medicines. This is when medicines use can be optimised and adherence improved. On top of that, there is an opportunity to provide healthy lifestyle interventions,” he explained. “Why would you advocate an alternative supply route that doesn’t add these critical values,” he asked.

Mr Holden believes that NHS England, the Department of Health and Public Health England need to develop a different mindset. “We are starting to see evolution happening with local authorities, which think more about what is right for the public. We need to see that shift in mindset and behaviours within the NHS, too; it’s about value across the system not just a silo cost.”

Transformational change

Chairman of NHS Bexley Clinical Commissioning Group Howard Stoate, who also spoke at the meeting, gave an insight into the financial pressures facing commissioners. He advocated the use of technology to improve patient outcomes and save money, advising pharmacists to be innovative. “I don’t want to see the same things done in the same way with a 5 per cent saving. That will not achieve the aims that I’ve got and ultimately it won’t deliver what the NHS needs.”

He would like to see 24-hour helplines for patients as well as more advice given over the telephone, the internet and through Skype on how people can manage their medicines.

Dr Ridge also mentioned the use of Skype, saying that he sees no reason why, over a period of time, pharmacy cannot “maximise the use of technology in its various forms, not just automation but Skype and all the rest of it, to be able to fit the modern world”.

Dr Stoate urged pharmacy to “think big”, explaining that to meet the financial challenges facing the NHS, tweaking services — such as pharmacists taking on work that GPs used to do — will not be good enough. Although freeing GP time could be part of the solution, he said, completely new ways of doing things are needed. “I’ve got to save £10m by next March. I can’t fiddle around with bits and pieces. . . . I need to make some massive changes. Transformation is what we need,” he said.

Mr Holden warned that pharmacy must come up with a cohesive and sustainable plan about its future direction fast or risk the health and social capital of the pharmacy infrastructure being undermined. “I hope that the work that Clare Howard [England’s deputy chief pharmaceutical officer] is leading on a community pharmacy strategy for NHS England will take us there, work that will be underpinned by Pharmacy Voice’s original prospectus, the PSNC’s recent vision document and some excellent outputs of the Pharmacy and Public Health Forum,” he said.

Dr Ridge echoed this thought at the meeting. Referring to the community pharmacy strategy, he said: “I just wonder if, somehow, we can all use that to bring strands together and, once and for all, just get on with it. There is no doubt pharmacy is heading in the right direction, but the public continues to wait for more. The opportunities are there . . . but the public, like the rest of us, are growing increasingly impatient.”

The outcomes of the Royal Pharmaceutical Society’s work on future models of care will be revealed in a report due out next week. Perhaps these, too, will provide some clues about the size of the pharmacy network that will be required to meet the future needs of patients and the NHS.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11129484

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