The new abnormal: vulnerable patients hit by pharmacy closures
In the first eight months of 2020, 155 community pharmacies closed down in England and — with many more at risk — and it is the elderly and most vulnerable who are set to be worst affected by the resulting gaps in service provision.
The COVID-19 pandemic is putting huge additional pressure on an already underfunded community pharmacy sector, resulting in many pharmacies closing down — with previously thriving businesses struggling and going under.
This year, pharmacy owner Stuart Gale had to take the incredibly difficult decision to close down one of his three Frosts Pharmacy branches in Oxford. “We have tried to keep it going as best we can. Local residents were really disappointed, they liked the pharmacy,” he explains.
Luckily, Gale was able to relocate patients and staff to another branch, but it has not been easy: “They now have to go more out of their way, it’s on a busy road, the shop is busier, and it will be difficult for some to get there,” he says.
Gale is one of scores of pharmacy owners who have had to take similar tough decisions this year. An analysis of NHS Digital figures by The Pharmaceutical Journal shows that in the first eight months of 2020, 155 community pharmacies closed in England, an increase of 77% in net closures on the same period last year.
The Pharmaceutical Services Negotiating Committee (PSNC) attributes the rise in closures in 2020 to the ongoing underfunding of the sector, which “the additional pressure from the pandemic has only exacerbated”.
According to a report by Ernst & Young, the sector is being underfunded to such an extent that, by 2024, up to 85% of the sector will be in financial deficit, likely resulting in a “contraction of the [community pharmacy] network”.
But the pressure has been piled on hugely by the COVID-19 pandemic.
The National Pharmacy Association (NPA) warned in May 2020 that pharmacies could close owing to the “considerable costs for staying open throughout the coronavirus crisis, including large increases in staff and medicine costs, outlays for security, [personal protective equipment] and deliveries”.
The PSNC’s bids to the government for additional funding to cover these costs have so far been unsuccessful.
Gale says that it is “extraordinary” that the branch he had to close was selling 5,000 items a month, but was still not financially viable. This proves — he says — that the businesses that are going under are not marginal.
And now, he says, they are struggling to cope with demand for deliveries; are having to work out of a stockroom converted into a cramped extra dispensary; and have had to cap numbers for flu vaccines, as demand is so high that they have run out of stock.
We do more and more for less and less, so I really do think patients will see a shrinking of service
Gale adds: “It’s just not sustainable; the pharmacy service will crumble. We do more and more for less and less, so I really do think patients will see a shrinking of service.
“Pharmacies are keeping all those people in their homes and they’re not paid for it and we’ll only notice when it’s gone. It feels like that day is getting closer.”
Speaking to local pharmaceutical committees (LPCs) around the country, that same concern is reiterated time and again.
David Dean, chief executive of Thames Valley LPC, says seven pharmacies in Oxfordshire have closed in the past six months, and he predicts that many others will see through the pandemic before also throwing in the towel.
He is “deeply concerned” that this will lead to gaps in service provision in the county, and it will be the elderly and most vulnerable who will be worst hit. Pharmacists are already having to put limits on some of their services, he adds, such as capping the number of medicines deliveries they undertake.
So far, the closures have yet to leave an area without a pharmacy, but he is worried that if the rate of closures continues, at some point, there will be whole villages or rural areas where patients have no access.
For many, pharmacy offers the only opportunity to obtain face-to-face advice about their medicine regime and minor ailments
“For many, pharmacy offers the only opportunity to obtain face-to-face advice about their medicine regime and minor ailments,” he says. “Some prescriptions can be delivered by online companies, but for many of the elderly and most vulnerable, this remains inaccessible.”
He points to figures from a PSNC audit in September 2020 showing community pharmacy is carrying out one million consultations every week, yet a recent survey from the NPA showed that half of pharmacy owners were planning to sell their businesses. And many are reducing the hours they are open.
Even if there are two or three pharmacies near to each other, when one closes those patients have to be absorbed elsewhere. Andrew Hartley is acting chief officer for Sheffield LPC, which has seen two recent closures of pharmacies each doing in excess of 15,000 items per month, which resulted in a big fallout.
“The pharmacies that are closing would have traditionally provided flu vaccination and now they can’t, and the other pharmacies may not have supplies,” he says.
There were a high number of patients on Nomad boxes who needed relocating with two to three months’ notice — which is not a lot of time to find a solution for these patients, who have complex needs, and for a service that is unfunded, he adds.
“Transferring these patients is not a simple process; the minute you have a complex patient that’s a whole different ball game, with a lot more challenges.
It’s your vulnerable patients with specialist drug orders, high intensity patients — they are the ones immediately at risk
“It’s your vulnerable patients with specialist drug orders, high-intensity patients — they are the ones immediately at risk. If they are housebound, they have to start ringing around, trying to find someone to take them on, and they’re scared and frustrated. For most people in that situation, that’s quite a frightening scenario — not sure where to go and what to do.”
Some pharmacies operating close to other pharmacies that have closed or consolidated say they have seen an increase in patients moving to them because they are more accessible than the alternative that was given to the patient.
Ann Gunning, North Tyne LPC’s head of services and support, says this is the reason for the increase in patients seen by one pharmacist she spoke to, as well as “some patients changing nomination due to the service level from the alternative pharmacy”.
Amanda Smith, vice chair of Community West Yorkshire and pharmacy manager at Heath Pharmacy in Halifax, says the closure of an independent pharmacy about a mile away, after it was bought out by another contractor, has sent an influx of new nominations to her pharmacy.
“It’s not a significant difference in travel, but we’re doing deliveries and that has been the reason for some nominations changing. We’re having to say no to some deliveries because we just can’t do them all,” she says.
Everybody is under pressure. All of us are really struggling. There are no plans for the closures — it’s just random, it could be anyone
“Everybody is under pressure. All of us are really struggling. There are no plans for the closures — it’s just random, it could be anyone. There’s no thought going into it.”
Once a pharmacy closes, that relationship with the patient is lost, which impacts on their care, she points out.
And she says they already get a lot of complaints from older patients frustrated that their GP is now online or phone access only, and they would not want pharmacy to be the same.
According to the NHS Digital figures, there have been nine closures across Derbyshire and Nottinghamshire this year, which has meant other pharmacies having to take on hundreds more items and requests for monitored dosage systems.
David Evans, vice chair of Derbyshire LPC, says there have been occasions with mergers where the more difficult patients have not been taken on. “At the moment, patients are not left without services as we are all trying our hardest to absorb that, but there is a risk that it could happen,” he says.
His view is echoed by Rob Severn, chair of the neighbouring Nottinghamshire LPC, who adds that pharmacies dropping supplementary hours is also having an impact on patients.
On 6 October 2020, Rowlands announced that it was planning to cut its opening hours, owing to “the level of funding” in the community pharmacy sector.
“If it’s a weekend, and you have a young family, and you need reassurance or medicines availability and you’re struggling, it means you can’t get access to a clinical expert without a drive or bus journey on public transport to a pharmacy in a different area,” Severn says.
While rural pharmacies may have been protected to a certain extent from closures so far, reducing opening hours can have a particularly large effect in these areas, he adds.
“It would be interesting to see what the number of supplementary hours lost across the country adds up to in terms of full-time equivalent pharmacies.”
A spokesperson for the Department of Health and Social Care says that “maintaining access to NHS pharmaceutical services is a key priority”.
“Eighty per cent of the population is within 20 minutes’ walking time of a pharmacy, and the government’s Pharmacy Access Scheme protects access in areas where there are fewer pharmacies and higher health needs.”
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2020.20208448
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