The challenges we share with some EU countries: what can we learn?
It is easy to say pharmacy in the UK is all doom and gloom. But are we really doing that badly? John Chave compares us with some European countries
Is the current pharmacy model sustainable? How do we develop new services? How do we get governments to better understand and appreciate our contribution? Will there even be pharmacies in the future?
If that sounds familiar, you are not alone. The same conversation is taking place across the European continent. Diverse as European pharmacy systems are, the challenges we face are surprisingly similar, and the pressures we are under disturbingly widespread.
So how are our European colleagues faring in answering these questions? And do pharmacists in the UK, in so many ways the vanguard of community pharmacy practice in Europe, have anything to learn if they peer across the channel?
What is German for “chain”?
If you take a trip to Paris, or perhaps visit Majorca on your holidays, you will notice a few things about French or Spanish pharmacies. They are all independents. There are plenty of them. And they are the only places where you can get anything to treat that holiday hangover.
France and Spain are two of the countries in Europe with the strictest level of regulation. All pharmacies must be owned by pharmacists. Chains are banned. A version of control of entry prohibits the establishment of new pharmacies unless certain distance and population criteria are fulfilled (making it more or less impossible to open new pharmacies, although, as the Figure illustrates, both have much higher pharmacy densities than the UK). And pharmacies have the exclusive right to sell non-prescription medicines.
Other large European markets are also strongly regulated. There is no control of entry in Germany, but chains are not permitted. In Italy, you can buy over-the-counter medicines in supermarkets, but pharmacy ownership and establishment are restricted. The countries in the EU which are totally liberalised (no restrictions on chains, general sales of OTC medicines and no control of entry) are in the minority, as the Figure above illustrates.
All this might have changed a few years ago, when the European Commission challenged ownership rules in the European Court. (The European Commission strongly supports free markets, a point sometimes lost in the UK debate on the EU.) Another European court case considered control of entry restrictions. In both cases the European Court ruled that restrictions are justified on public health grounds and are therefore lawful.
The victory was celebrated by pharmacists in countries such as Germany, Italy and France, but the reality is that the threat of liberalisation has never gone away. Since the early 2000s, governments in Ireland, Norway, Sweden, Portugal, to an extent in Italy, as well as in a number of countries in Eastern Europe, have removed restrictions. This year the Spanish government flirted with the idea of permitting chains and may do so again. Opposition parties in Italy favour ending the ban. In France, pharmacists are engaged in a fierce battle with their own competition authorities to preserve the OTC monopoly. Even German pharmacists are pessimistic about the chances of excluding chains in the future.
It is therefore something of an irony that the UK, seen from the other side of the channel as source of poisonous free market dogma, has just made control of entry more restrictive, a move that bucks the European trend.
Austerity and its discontents
In Portugal, the national pharmacy association has launched a campaign called “Farmacia en luto” (pharmacy in mourning). Over one-third of Portuguese pharmacies are trading at a loss. Widespread closures are seemingly inevitable. Portugal is, of course, subject to severe public spending cuts, as are all countries subject to a European bail-out. But no pharmacy system has emerged unscathed from the European economic crisis. Even in countries such as Finland or Sweden, where the impact of crisis has been relatively mild, pharmacies are taking an economic hit.
Governments just about everywhere have discovered a taste for cutting pharmacy budgets. When they are not directly cutting payments to pharmacists (eg, Ireland), they are driving down the prices of medicines, particularly generics. On the whole, generics have traditionally been relatively expensive on the continent compared with the UK. Price cuts are a huge problem if your remuneration relies partly on discounts (eg, the Netherlands) or, worse, where you are paid a mark-up on the price (most European countries).
The UK system of global funding, fees, allowances and clawbacks differs in key respects from most other remuneration systems in Europe. In many countries, when prices fall, then so does pharmacy remuneration. This is so even if percentage mark-ups are relatively high, given the low prices of generics and their increasing use. As a result, there is now a scramble to reorient payments systems away from fixed percentage mark-ups and toward fees.
Again, the UK compares favourably. Although the economic environment is tough, the relative stability of the funding of the system as a whole leaves pharmacies less exposed than many of their European counterparts.
The UK example
A friend recently visited a Belgian pharmacy and inquired about the possibility of having her blood pressure measured. A puzzled looking pharmacist replied: “But madame, I can’t do that. It’s illegal.”
You will not see the range of services provided in many UK pharmacies anywhere else in Europe. Even in mature, high-quality markets like Germany, additional services provision is small scale and privately paid for. Most pharmacies on the continent offer a dispensing-and-advice model which has not evolved much for decades.
Why? The kind of legal restrictions witnessed by my friend in Belgium are widespread, underpinned by strong opposition from the medical profession to any significant development of pharmacy-based services. Unlike GPs in the UK, doctors are often paid per visit and not on a capitation basis, and they fear a loss of income and status if pharmacists expand their role.
The NHS, so often criticised for being static and unresponsive, is a hotbed of radical innovation so far as pharmacy is concerned, at least compared with some of the semi-autonomous social insurance companies that fund many continental health systems. And there are some who even argue that the restrictions in place to protect independents stifle professional evolution.
Things are changing, if slowly. Belgium and France have just put in place their own version of the new medicine service. In the Netherlands, a range of new services is now available and funded. The Irish have embraced vaccination, as have the Portuguese. But pharmacists in the rest of the EU are still given to looking enviously towards the UK shores. Aspects of pharmacy professional practice, which are now taken for granted in the UK, for example, pharmacist prescribing, are beyond the wildest dreams of most.
Can we learn from the rest of Europe?
So pharmacy elsewhere in Europe is being pummeled by deregulation and austerity with little scope for developing new business models in the form of services. But there are also some instructive examples of excellence.
Take the “Dossier pharmaceutique” (DP) in France. The DP is a pharmacy-based electronic medication record designed and implemented by pharmacists themselves and now available in nearly all French pharmacies. It allows any pharmacist in the country to consult four months of patient medication history, both prescription only and OTC medicines (the OTC monopoly comes in handy) with the patient’s consent, of course.
Studies show the system has made significant inroads into the problem of prescription errors and previously undetected adverse drug reactions. The French are now going to connect the system to hospitals in order to create what would be the first large-scale electronic medicines reconciliation system in Europe. The UK is moving in the right direction on this issue, but the French are already there.
Or take the Dutch system of pharmacist-GP collaboration. It is widely recognised in the UK and elsewhere that, if pharmacists and GPs were to work together more closely, medication safety and effectiveness, as well as overall care, could be improved. In the Netherlands they take this proposition seriously. Pharmacy and GP records systems are increasingly integrated. Pharmacists receive laboratory test results and can read the diagnosis on the prescription. The two professions meet and review treatment. Although often the professions are housed together, it is illegal for GPs to own pharmacies. The Dutch system is arguably a model for the future of primary care.
In general, there is something to be said for restrictions. Few countries in the rest of the EU tolerate sale of prescription medicines though the internet. And the industry has failed to impose direct-to-pharmacy distribution anywhere else in Europe on any serious scale, substantially as a result of legal impediments. Indeed, many of the aggressive business models which UK pharmacists find threatening are hardly to be seen elsewhere.
Finally, although all pharmacy systems are different, in many ways we are becoming more integrated. Collaboration on a policy level between European governments has never been deeper — witness the wildfire spread of generics pricing policies over the past four years.
Pharmacy stands or falls, in the UK and everywhere, on its ability to show it meets a public need worth paying for. There are plenty who argue that technological change, from Amazon-style distribution to mobile apps, challenges retail business and intellectual services. Pharmacy is both of those.
If pharmacy struggles or prospers in the future, the same considerations will ripple round the continent. In Europe, in a certain sense, we are in it together.
See also: Focus — community pharmacy
The issue of Focus in which this article appeared was supported by GSK
Citation: Supplements DOI: 10.1211/PJ.2014.11134173
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