Brexit: Health Policy

Baroness Jolly Excerpts

Wednesday 6th December 2017 Lords Chamber

[Lord O’Shaughnessy]

My noble friend gives a wonderful exposition of the values of democracy, which I wholeheartedly endorse. I should point out that the UK Government are implementing the wishes of the British people, as expressed through the referendum, and that this position was supported by the manifestos of parties that gained 80% of the vote at the most recent general election.

[Baroness Jolly (LD)]

My Lords, EU workers comprise some 5.6% of the healthcare workforce overall, including 10% of our doctors and 7% of our nurses. Most of these workers, who are not trained in the UK, are able to come and work here through the EU mutual recognition of professional qualifications directive. Can the Minister reassure the House that these reciprocal arrangements are afforded to EU and UK health professionals in perpetuity?

[Lord O’Shaughnessy]

The noble Baroness is right about the important role that EU workers play in the NHS, and I pay tribute again to the work that they do. We value them and want them to stay. We are in a position with the stock of EU workers here—and, equally, UK workers in other health systems—to recognise those qualifications. Clearly we will have to agree to continue doing that as part of the future negotiations. It has to be said that some concerns have been expressed by bodies such as the GMC about how that operates. We are working with them to make sure we get that right.

HIV Prevention Services: Public Health Funding

Baroness Jolly Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord O'Shaughnessy]

First, I pay tribute to the work of the Terrence Higgins Trust and its leadership in this area in making progress in the UK in dealing with the HIV/AIDS epidemic. The delivery of open access to sexual health services is mandated for all local authorities, which are funded to do so by the public health grant. It is incredibly important to point out that over the last four years there has been a 500,000 increase in the number of attendances at sexual health clinics, and more testing and treatment is taking place. That is starting to show in the reduced number of diagnoses, as well as in other factors. It should also be pointed out that as regards looking after those suffering from the consequences of HIV/AIDS, the Care Act 2014 is extremely clear that the legal framework for social care applies to adults, including those who live with HIV.

[Baroness Jolly (LD)]

My Lords, very large populations of gay men live in metropolitan areas such as London and Manchester, but my question is about the far-flung corners of the country: the north-east, the north-west and the south-west. Can the Government be confident that young men are able to access services and have PrEP available in those sorts of areas?

[Lord O'Shaughnessy]

The noble Baroness is quite right to point out the difference. If you look at the performance in London against the UNAIDS 90-90-90 targets, you will see that they have been met. However, England as a whole is at least slightly behind on at least one of those factors—people with HIV not being diagnosed—which points to the fact that out of metropolitan areas there is more work to do, as she says. One of the ways in which local authorities meet that challenge is through offering home testing kits, which are being sent out and which are now seeing the kind of return and diagnoses levels that you would see in sexual health clinics.

NHS: Staff

Baroness Jolly Excerpts

Thursday 30th November 2017 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I join other noble Lords in thanking the noble Lord, Lord Clark of Windermere, for calling this debate, and other noble Lords for their excellent, expert contributions. I shall, in the main, address issues around nurses but much of what I can say will apply to doctors, other clinicians and healthcare professionals.

The Government’s policy has been to take the view that if you pay less you can afford to employ more with the same money. This might be all very well in an industrial context. If you need a commodity to manufacture a widget and you can get it cheaply at the same quality, you can get more widgets for your money. However, we are talking not about manufacturing but about the men and women that the state employs to care for those in our society who are ill. Many of those staff have years of training or experience, and some of them could earn more in the private sector or in health services abroad.

It is the people whom the noble Lord, Lord Clark, has asked us to consider in this debate, but first we must look at the money. I have a paragraph spelling out the numbers but the noble Lord, Lord Warner, has beaten me to it and I shall not repeat them. They should be taken as read. However, the wider financial pressures in the NHS were not addressed adequately in the Budget. Before the Budget there was an assessment of the NHS financial requirement for the future from the respected trio of the King’s Fund, the Nuffield Foundation and the Health Foundation, indicating that £4 billion was required. The Chancellor committed less than half of that. Undoubtedly, part of the recruitment and retention problems the NHS is experiencing is linked not only to pay but to the pressures that staff are put under to continue delivering high-quality services with insufficient resources.

For the record, the Lib Dem policy of a penny-in-the-pound rise on all income tax bands and dividends would raise around £6 billion a year. This would be a hypothecated tax and would go some way to allowing the NHS to recover and grow again. As many Peers have said, we all waited in vain during the Chancellor’s speech for a mention, no matter if brief, of social care. Can the Minister indicate how the Government anticipate supporting the care sector to grow and relieve the NHS of those who are in its beds when there is no further need for healthcare? Is the market expected to address this? It is local government’s responsibility to shape its local markets. This seems patchy at best. Will the Minister tell the House where local authorities could look to see good practice in this regard? Without addressing the issue of those unable to move out of acute care to either a care home or a package in their own homes, productivity will be a difficult ask.

We know that demand will rise, that the ageing population is growing and that treatments to manage and cure illnesses will improve, but often at increased cost. What is new? What might be done to narrow the gap? We look at the women and men who so valiantly and professionally care for our sick. I have spent some considerable time recently in my local acute hospital and then a local community hospital where my mother—frail, demented, and very elderly with failing heart, eyesight and hearing—has received professional care and attention. She was typical of most in her ward, and I watched as she became the policy stereotype whom we debate here. Those teams, nurse-led, are without a doubt stretched. They went home after their shift exhausted but I was certain that they knew what “excellent” looked like and they strove to deliver it. They are all in the mould of the noble Baroness, Lady Emerton, whose wise words we will indeed miss.

However, we know that anecdote should not deliver policy but that sufficient evidence should inform it. I therefore offer the staff survey carried out by the NHS last year. It showed that 36.7% of respondents reported feeling unwell as a result of work-related stress. In 2015, a different survey carried out by the Guardian found that 61% of healthcare professionals reported feeling stressed all or most of the time. Whichever number you take, it is too many and is good for neither recruitment nor retention, nor morale.

The Government’s continued insistence on a pay-rise cap of l% for public sector workers did untold damage to recruitment, retention and morale among the NHS workforce. In July, the BBC reported that more nurses and midwives are leaving the profession in the UK than joining it, for the first time since 2008. The number registered in the UK fell by nearly 1,800 to 690,773 in the year to March. Full Fact reports that, overall, nearly 35,000 nurses and midwives left the Nursing and Midwifery Council’s register in 2016-17. This does not bode well and has to be addressed. We need to value our staff, and I welcome the Chancellor’s statement that he will remove the cap on public sector workers’ pay and review the Agenda for Change pay awards—albeit conditional on increased productivity, staff recruitment and retention. This is the nub of our debate.

Agenda for Change receives recommendations from the NHS Pay Review Body on recommended pay uplift. It is an independent body. Will the Minister describe the mechanism by which an independent body can make recommendations that appear to be predetermined by the Chancellor? For productivity, we need to look at our staff—from the cleaners to the consultants and, importantly, to the boards of our NHS trusts—to examine the bottom line of the balance sheets differently. They should ask not what can be cut but what can be done differently. They need to look at all their staff as agents of change and look at what other trusts do differently. Each unit needs to become a learning unit, whether that is A&E, a children’s ward or the chief executive’s office. They need an overall aim, made up of small and achievable bite-size aims. They need to measure progress, be proud of their achievements and be willing to share them.

This is nothing new, but people need to be given time to think about what they do, and permission to get off the treadmill and consider what small changes would make a large difference to their working practices and the care of their patients, and we should reward shared innovation. If we crack this, productivity should improve, as should morale and retention—although retention also depends on reward.

The Health Education England CPD budget has been cut from £205 million in 2015-16 to £83.5 million in 2017-18. What are health professionals expected to do to keep up to date? The report from the Nursing and Midwifery Council last month states that nurses and midwives are already taking themselves off the register. The Minister has already given the House an assurance that the Government do not intend to recruit from the third world, so how is this to be resolved in the short term? We have had long-term answers, but it is a short-term problem. What plans are in place to entice back nurses working elsewhere and to train more? What sorts of gaps are anticipated? What is current thinking?

Attracting people to train as a nurse would be easier if the bursary were reinstated. It is not just about money. It sent the wrong message to bright young people attracted to a profession that is not well paid. It needs to be reassessed and reinstated.

For a Lib Dem, I have done quite well speaking for so long without mentioning Brexit. The NHS has had years of employing staff from our fellow EU states at all levels of the NHS—and, indeed, in health research. Yesterday, the Association of Medical Research Charities was having a Westminster day meeting parliamentarians from both Houses. I met four chairs who were really alarmed at the implications for medical research outside the EU. They told me that they had met the Minister but were still in need of assurance. Where do the Government stand on that?

To increase recruitment and retention, we need to raise morale and involve staff in the solution to the problem. We need to pay them a fair wage. We need to continue to encourage and fund professional development. We need to cast the net widely to recruit at home and abroad, because we need an NHS prepared for the next 70 years and the challenges, which the noble Lord, Lord Warner, outlined, that that will surely bring.

Mental Health Care: Vulnerable Children

Baroness Jolly Excerpts

Tuesday 28th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I can reassure the noble Lord that spending on children and young people’s mental health by CCGs, which are responsible for commissioning those services, increased by 20% between 2014-15 and 2015-16, so spending is increasing. Clearly, one of the areas in which that money is being spent is on better facilities. One of the additional changes is that about 150 new beds will be commissioned in underserved areas so that we can reduce the number of out-of-area placements, which can be quite disturbing for some of the children and young people who have to use them.

[Baroness Jolly (LD)]

My Lords, in England there are around 60,000 looked-after children, and there is evidence that some health providers are denying treatment to looked-after children if they have not yet established a permanent living situation. This is completely unacceptable. What action are the Government taking to ensure that all children’s care is addressed? Will the Minister confirm that the long-awaited Green Paper will be published this year?

[Lord O'Shaughnessy]

I ask the noble Baroness to write to me on that specific case. Of course, health services should never be withheld on such a basis; they should be provided on the basis of need, as we all know. I can confirm that the Green Paper will be published before the end of the year.

Maternal Safety Strategy

Baroness Jolly Excerpts

Tuesday 28th November 2017 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for repeating this important and very serious Statement today. To lose a baby is a heartbreaking matter for parents and families, and something from which sometimes they never recover. Clearly, it should not be so hard for parents to find out what may have gone wrong and why they do not have the healthy baby that they were so eagerly anticipating. So it is quite right to have a much simpler and more transparent process to find out whether anything went wrong, what it was and whether it might have been avoided, and to apologise in a timely fashion if things went wrong.

I welcome the announcement that all notifiable cases of stillbirth and neonatal death in England will now receive an independent investigation by the Healthcare Safety Investigation Branch. The HSIB is a new organisation; are we going to see primary legislation in this Session establishing it? This development is definitely an important step that could bring certainty and closure to hundreds of families every year. We on these Benches also welcome the moves by the Secretary of State to allow coroners to investigate stillbirths. There is much else to welcome in this, including the tobacco control plan, which is a passion of my own.

Our National Health Service offers some of the best neonatal care in the world, and the progress set out today is a tribute to the extraordinary work of midwives and maternity staff across the country. However, it is shocking and heartbreaking that in nearly 80% of the cases referred to by the Minister, improvements in care might have made a difference to the outcome for the baby when things have gone wrong. There is no doubt that staffing shortages mean that midwives are under enormous pressure, which can lead to situations that have a devastating impact on families. While of course we welcome the Secretary of State’s ambition to bring forward to 2025 the target date for halving the rate of stillbirths, neonatal deaths, maternal deaths and brain injuries that occur during or soon after birth, that can be delivered only if the NHS units providing those services are properly resourced and properly staffed.

I looked in vain for something in the Statement to tackle the low levels of maternity staff, an issue that is clearly linked to safety. Noble Lords will know that the heavy workload in maternity units was among the main issues identified by today’s report, with service capacity in maternity units affecting over one-fifth of the deaths reviewed. Earlier this year, research revealed that half of maternity units had closed their doors to mothers at some point in 2016, with staffing and capacity issues the most common reasons. The Royal College of Midwives tells us that we are around 3,500 midwives short of the number needed, and this summer, for the first time, there were more nurses and midwives leaving the register than joining it. This issue will be exacerbated by the fall-off of new recruits from Europe post Brexit.

A survey published by the National Childbirth Trust this year showed that 50% of women having babies experienced what NICE describes as a red-flag event. These are indicators of dangerously low staffing levels, such as a woman not receiving one-to-one care during established labour. What action will the Government take alongside some of these excellent proposals properly to address the staffing shortages as part of the strategy to improve safety? I hope that the Minister can reassure us today that the Government will provide the resources that NHS midwives and their colleagues need to deliver on these ambitions.

Finally, if and when parents resort to legal remedies, as they sometimes feel they have no choice but to do, do the Government intend to deal with the performance of the NHS Litigation Authority in terms of both timeliness—acknowledging fault in a timely manner—and learning lessons which are properly disseminated? As the Minister quite rightly said, we must have a learning culture, but one area which fails is the conduct of the NHS Litigation Authority.

I thank the Minister for the Statement, and we would be very interested in working with him to put legislation on the book that makes these proposals happen.

[Baroness Jolly (LD)]

My Lords, I pay credit to our midwives, who do a wonderful job all across the country, and to those who campaigned to get the report and have spoken about it—I woke up this morning to a very moving Radio 4 piece on the “Today” programme.

I also welcome the Statement from the Secretary of State. Bereaved parents certainly want an answer, and this is an ideal way of helping them to reach some sort of closure. One of the critical points that the Each Baby Counts report makes about maternity care is the importance of continuity of care both for the expectant mother and for the team in the delivery suite. Staffing is an issue, with the workforce being short by 3,500 and a third of our midwives approaching retirement. Some midwives are adopting different patterns of work or choosing to leave the profession, but temporary midwives, be they bank or agency, are not the solution. They undermine the continuity that is so critical. A perfect storm is approaching about recruitment and retention.

Will the Government reconsider some form of financial support for midwives in training? Are any other incentives being considered? Will they guarantee an NHS midwife who is an EU national a job should we leave the EU? What measures are being considered to bolster the morale of NHS midwives, because at the moment, it is really quite low?

[Lord O'Shaughnessy]

My Lords, I thank both noble Baronesses for their overall support for the important announcements made today, and join them in paying tribute to both the staff, who provide amazing care every day, which of course is the norm for most parents, and those campaigners who have campaigned so bravely to raise the profile of these issues with great success.

I shall deal with the issues raised in order. First, on legislation, it is important to point out that the Healthcare Safety Investigation Branch is up and running. Obviously, the intention is that the Bill will put it on a statutory basis, which will give it a degree of security and continuity. Draft legislation will be considered by a committee before turning it into a fully fledged Bill. Although I am not entirely sure of the timetable, I reassure the noble Baroness that we intend to have proper primary legislation following consideration of the draft Bill.

It is important to recognise that the number of staff has increased in the past few years, whether maternity nurses working in maternity services and neonatal nursing, midwives or doctors working in obstetrics and gynaecology. It is also important to recognise, first, that the number of births has risen, so there is a greater workload; and secondly, that on average births are becoming more complicated, as mothers become older, on average, and have more concomitant health problems—smoking and obesity are two of the greatest. I recognise the challenge.

I should point out that more than 6,800 midwives are in training, so there is an intention to continue growing the workforce. However, I recognise that more needs to be done to support them so that they can deliver the care. That is why the training packages announced today are so important.

In terms of learning lessons, the whole point of the rapid-resolution redress process by involving the HSIB is to provide resolution to parents so that they are satisfied while avoiding the sometimes adversarial situation that can emerge, when all that happens is that the problem is delayed for 10 years and creates great heartache for the families involved. We are trying to come up with a process that deals with it more quickly, without disadvantaging the families concerned, and means that it is easier to spread the lessons. That is why the independent HSIB investigations are so important.

Finally, I emphasise the point about the importance of continuity of care, which is referred to on page 16 of the maternity strategy. Here is a stark fact: women who receive continuity of midwife-led care are 16% less likely to lose their babies. That is about one in six, an extraordinary statistic. I understand that it does not necessarily require more staff to deliver that but it does require staff to be organised differently. That is one of the challenges that we have ahead.

Brexit: Mental Health Research Funding

Baroness Jolly Excerpts

Thursday 23rd November 2017 Lords Chamber

[Lord O'Shaughnessy]

In relation to the NIHR funding that I talked about and the specialist disease areas that receive funding, mental health is second only to cancer, so it is getting a great deal of funding. I could talk about the increase in the Medical Research Council’s budget and so on, but more funding is going in specifically to mental health research.

[Baroness Jolly (LD)]

My Lords, the UK is currently the second-largest receiver of research funding from the EU—second only to Germany—and is among the most productive places in the world in mental health research output. Does the Minister share my concern that the best will follow the money to the USA or elsewhere?

[Lord O'Shaughnessy]

As I set out in my Answer to the noble Lord, Lord Brooke, the intention is to continue our relationship with and involvement in cross-EU health projects. Other third-party countries do that, and there is no reason why that would not be the case. In terms of the workforce, which I think is what the noble Baroness was referring to, the Prime Minister has been very clear that we want to continue to attract the brightest and best to this country. Once we have left the European Union, our immigration system will be set up to do just that.

NHS: Deficit

Baroness Jolly Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord O’Shaughnessy]

That is a completely unfair accusation and unjustified, both by the funding settlement that the NHS had and by the improved settlement today. First, deficits have been falling year on year for the past couple of years in terms of both outturn and forecast, and that is before today’s announcement on additional funding. The Chancellor today announced over £2.5 billion-worth of extra revenue funding over the next two years. That means that the actual value of the spending review settlement will end up being £11.5 billion compared with £8 billion, so I reject the idea that this Government are not funding the NHS properly.

[Baroness Jolly (LD)]

My Lords, the NHS is very nearly 70. There was some continued investment in today’s Budget, which we welcome, but we consider that it is only a sticking plaster unless we look at social care and the NHS together. If we want the NHS to continue for another 70 years, we really need to see a change. A cross-party group of MPs visited the Prime Minister and put that to her, suggesting that there needs to be an all-party conversation about this—an all-party commission. Will the Minister tell the House whether the Government are minded to pursue that and, if not, why not?

[Lord O’Shaughnessy]

As the noble Baroness pointed out, additional spending is going in. I should point out that the proportion of public spending on health has increased under this Government, so even while fiscal retrenchment has taken place, more money has been spent on health. On the idea of a cross-party convention, we talk about building a cross-party consensus on social care with the Green Paper that will come out in due course. We need to focus on action. The danger with conventions and commissions is that they just prolong the process of making decisions, whereas moving ahead with decisions on both integration in the NHS and getting consensus behind reforming social care is the way forward.

NHS: Wound Care

Baroness Jolly Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I join other noble Lords in thanking the noble Lord, Lord Hunt of Kings Heath, for calling this debate and the noble Baroness, Lady Wheeler, for being such an excellent substitute. It has been a fascinating debate, with much clinical and personal experience. There are many voices and players in this discussion: the clinicians, the commissioners, industry, those who are trying to improve performance and save money by rationalising systems and processes, and of course the patients, too.

I confess that I came to this subject completely cold and ill-informed. The debate covers: innovation and the management of wounds as a result of great British dressings with amazing technology, but, according to NICE, the need for a stronger evidence base; the escalating crisis in our nursing workforce; the need to share good practice in the NHS; decisions made by clinical commissioning groups; and, as ever, the money.

The cost of wound care—as others have said, around £5 billion each year—is the same as the nation’s bill for managing obesity. This came as quite a surprise to me. We have heard some really interesting numbers from both the noble Baroness, Lady Watkins, and the noble Lord, Lord Kakkar, and I have a few more. In 2012-13, there were 2.2 million wounds to be dressed and healed, 7.7 million GP visits and 3.4 million out-patient visits. The numbers suddenly become not surprising when it is patient-professional interactions and professional treatment that are increasing the costs, and not the dressings.

Much of the debate about wound care is about dressings and their cost. The Carter report talks about procurement but not the cost of treatment. If he had looked at total treatment costs, the story would have been very different. As a proportion of total cost, even some of the most advanced dressings are not hugely significant. What is required in this care—and I am sure that in most instances it is given—is a patient-centred decision, and I am sure the Minister would agree with that. I would like commissioners of such services to be mindful of this.

The area of innovation is quite a good British success story. We have interesting and new techniques that are used in dressings. Several noble Lords have spoken about AMR, and we need to be mindful of that. There are also smart dressings that will talk to your iPhone, or any other mobile phone of your choice. Also, the dressings are completely unlike those that I remember seeing my mother-in-law having to wear on her legs 10 or 15 years ago. The change in technology is huge. Hand-held technology can also be really important. All clinicians should have access to patient data from all NHS settings. Could the Minister tell us when this might really happen? How imminent is it? I think 2020 is the date we look for, and I would just like some clarification that this is still on track.

The noble Lord, Lord Kakkar, spoke about sharing good practice, which should reduce the variation in outcomes. There are clusters of really good practice, and one of the upsides of battlefield medicine is some of the treatments that have come from it for treating wounds. The noble Lord, Lord Colwyn, emphasised that. The use of communications technology assists with this, but we acknowledge that this will never replace the clinician-patient practice relationship.

Nurses are pivotal in delivering good care, and in the briefings that we have received there is considerable anxiety around the nursing workforce. Some 60% of NHS costs are in community settings—in our own homes or care homes—and we need to attract to the profession many more young men and women who are willing to take on this role. Careers advice and perceptions of careers in schools are not always absolutely as they might be—or indeed probably as they were 10 years ago. We need to examine the financial support given to nurses as undergraduates. We all know that nurses will not always be well paid—certainly not in the first instance—but bursaries should be part of the package. Professional development is also key to good practice, to retention and to making nurses feel valued and part of a team. What time is protected within clinical settings for nurse training and CPD?

Overseas nurses have always had a key role in the NHS—historically from the West Indies, south Asia and the Philippines, and more recently from EU states. Could the Minister confirm whether, to replace these nurses, there are any plans to recruit from third-world countries? I remember being at an NHS conference 19 years ago where the Health Minister of one of the southern African countries spoke very movingly about how much they invest in training their nurses, and we come along and offer better packages. We have sometimes to weigh up issues around third-world development and our own failure to train enough nurses here. The pay cap is hugely detrimental to nursing retention and the feeling of being valued. We have this perfect storm around the workforce, which gives us the loss of expertise of retiring nurses and the loss of EU nurses.

Finally, as noble Lords will know, I forgot that this debate was today—I thought it was tomorrow—so I was not as well prepared as I would like to have been. However, the House has really covered this issue well and at length. We have seen that there are huge advances in technology and in dressings, and that these are all moving faster than the regulators can deal with. From all that we have heard today and that I have read in the briefings, I endorse the call within the title of this debate for a strategy for dealing with wound care standards.

South East Coast Ambulance Service

Baroness Jolly Excerpts

Wednesday 1st November 2017 Lords Chamber

[Lord O'Shaughnessy]

My noble friend is quite right to make that point. There has been a big effort to install defibrillators in a number of public settings—they are throughout the Palace of Westminster and many other workplaces. They make a big difference to that immediate response where it is needed.

[Baroness Jolly (LD)]

My Lords, around a million calls a year are made to the South East Coast Ambulance Service and there have been many reports of technical problems with the service. According to a CQC report, the first reports of these malfunctions, which affected the recording of calls, occurred in June 2016. Does the Minister have any information on how many recordings were lost? Have the specific circumstances around any patient’s arrival to NHS premises been lost?

[Lord O'Shaughnessy]

The noble Baroness is right about the technical problems. I understand that two new systems have been put in to address those; one is a computer-aided dispatch system and the other is the moving of the emergency operating centre to new premises. That is part of the special measures investment that has been taking place to improve the quality of service.

Health: Flu

Baroness Jolly Excerpts

Monday 30th October 2017 Lords Chamber

[Baroness Jolly (LD)]

My Lords, the Minister has, quite rightly, said that community pharmacies are a really important place to seek one’s flu jab. However, the owner of Lloyds Pharmacy, Celesio UK, has announced that nearly 200 of its local chemist’s shops will cease trading. What assessment have the Government made of the potential clinical impact of this decision? What pressures will follow next winter as a result?

[Lord O'Shaughnessy]

I agree with the noble Baroness about the role of community pharmacy. It is worth bearing in mind that some 88% of people are within a 20-minute walk of a community pharmacy, which is accessible for the vast majority. There are also 20% more pharmacies than there were 12 or 13 years ago. Pharmacies have a critical role to play and are there in the community, but companies come in and out all the time.