Pharmacies and Integrated Healthcare: England

Julie Cooper Excerpts

Wednesday 11th January 2017 Westminster Hall

[Julie Cooper (Burnley) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Bailey. I thank the hon. Member for St Albans (Mrs Main) for securing this debate on a very important subject. It is pleasing to hear so much agreement around the room; I hope that the Minister is listening. I agree with most of what hon. Members have said.

This subject is very dear to my heart. My husband is a community pharmacist, and I worked with him for 24 years in our own community pharmacy in my constituency of Burnley; I have to add that we no longer have any financial interest in community pharmacy, but what I retain is a very deep understanding of the value of community pharmacy to patients, the community and the wider NHS, so I appreciate the hon. Member for St Albans securing this important debate.

I cannot think of a better way to demonstrate the value of community pharmacies than to talk about my experience. Coopers chemist in Burnley—a deprived constituency in many ways, where life expectancy is closer to 80 than 90—serves a community along with four other pharmacies in very close proximity, all of which are really busy and serve a big demand. On a typical day, we dealt with 600 prescriptions and 100 minor ailments, and ran many other services—forgive me if I forget some, because there were so many—including medication use reviews designed to maximise our use of medication, make sure patients understood it, encourage compliance and save money on wastage; smoking cessation programmes; dietary advice; emergency hormonal contraception; methadone programmes; and support for diabetics and asthmatics. It was an ever-increasing list. Those are the kinds of services that are at risk if the Government pursue their plans.

I appreciate the value of community pharmacies. I am also a former private business owner. Let us not forget that that is what community pharmacies are; they are not provided for and paid for by the NHS.

[Oliver Colvile]

That is a very good example of how the private sector, working in the national health service, can deliver good-quality services.

[Julie Cooper]

I do not disagree with the hon. Gentleman’s point.

It is important that we recognise that community pharmacies provide their own premises and train their own staff. As a former business person, I totally get the point about value for money, but this is not just about money; it is about the efficient use of money. We all understand the pressures that our NHS face, and we have to look at that. There are a lot of myths floating around, so it is important that we clarify that.

There has been a lot of talk about the clusters. Again, because pharmacies are private businesses, they respond to demand in the community.

[Julian Knight (Solihull) (Con)]

The hon. Lady brings her expertise to the debate. Does she agree that we need more innovative approaches? The Grove surgery in Solihull has a symbiotic relationship with its local GP services, but in parts of the UK we seem to have run into the sand. We need greater public awareness and encouragement to take such innovative approaches forward.

[Julie Cooper]

I will come on to that very point in a moment.

To return to value for money, it is important that the Government take a responsible attitude and review funding for pharmacies, and I think that professional community pharmacists across the country accept that. Much has been made of the clusters. Pharmacies are independent businesses that arise and stay in business where there is demand. I do not know whether this is widely understood—hon. Members will have to forgive me if they already know this—but the global sum allocated to pharmacies is what pharmacies cost the Government. The Government know what community pharmacies are going to cost. If a new one opens, it does not cost the Government any more; it just means that the same amount of money is shared out more thinly. That is a bit of a red herring. We can be sure that if there is no demand for the services that a pharmacy provides, it will close.

Much has been made of the £25,000 payment, but that does not cover the cost of putting a van on the road and paying for a driver to deliver and administer a prescription delivery service. Those services are absolutely invaluable to communities with many elderly people. I had a conversation with practice managers and general practitioners in my constituency recently, and they were absolutely horrified because they use that service—there is a lot of repeat ordering—and if it were lost, they could not cope.

The Government are suggesting that in-surgery pharmacists are a substitute, but that is another red herring. I welcome the use of well-qualified pharmacists in GP surgeries, but that is a totally separate issue. It is like comparing hospital doctors with GPs. Community pharmacists are at the heart of the community and are accessible for many hours. The hon. Member for St Austell and Newquay (Steve Double) made the point very well earlier when he said that eight minutes is the average wait to see a qualified professional who can help with most things. We have got to embrace that and use what is already there.

I have had conversations with the National Pharmacy Association and the Royal Pharmaceutical Society, and just last night the chair of the English Pharmacy Board said, “We want to work with the Government. We want to sit down and look at how we can do more.” There is the idea that integration is a new thing waiting to happen, but we were proud as community pharmacists to be at the heart of the primary care team, working with GP surgeries, hospital discharge teams, community nurses and district nurses. They often came to us. GPs came and went—that is even more the case now, given the problems with retention in GP practices—so we provided the only continuity in healthcare for many chronically ill people. Particularly for the elderly, that was a vital part of the service, and we were really proud to provide it.

Many community pharmacies are proactive. When this business of moving towards a clinical approach was suggested, community pharmacies accepted it without it needing to be mandated. We invested in a purpose-built consulting room to provide a more clinical environment. That is the way forward, and most community pharmacies accept that.

What is the alternative to what the Government are proposing? For a start, we need a proper assessment of what the cuts will mean. There has been no impact assessment of which pharmacies will close. I agree with the hon. Member for Bury St Edmunds (Jo Churchill) that it will not be the multiples that will close; it will be the independent pharmacies that rely on the £25,000 to provide their core services. That is an absolute fact. Not a single pharmacy in my constituency qualifies for access payments, and only three in the entire city of London do. I can say with absolute confidence that in my constituency it will not be Boots that closes or cuts its hours; because of the volume of business, it has other ways of covering its overheads.

I ask the Government not to throw money willy-nilly at pharmacies, but to look at their value and assess the impact of the cuts. If they think that the best way forward is for some pharmacies to close, they must ensure that the right ones close. We must do what the professional organisations are asking for and come to the table. Pharmacies are begging to take on extended roles. There is so much good will there. The minor ailment scheme, which we were privileged to provide, is an important service. Busy families who have children with minor ailments do not have time to be at the GP surgery. GPs accept that, without that service, they could not manage. We all know that GPs work hard and are overstretched. This is not about criticising the work they do; it is about supporting them, saving the NHS money and taking off pressure.

I ask the Minister not to reconsider the funding, but to look at the way he works with pharmacies in the NHS. I ask him to look at their role, as many Conservative Members have said, and at how they can work with the Government to support other areas of the NHS, thereby saving money. Let us avoid a knee-jerk reaction with no proper assessment of the impact. Let us deliver a better integrated service. The way to do that is not to make blind cuts with no proper assessment.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship, Mr Bailey. I congratulate my hon. Friend the Member for St Albans (Mrs Main) on leading the charge on what we all agree is an important subject. We have heard some very useful speeches, although I would make the point in passing that the subject is apparently so important to the Opposition that there have been no speeches from their Back Benchers on any aspect of the reforms during the last hour and a half.

My hon. Friend used an important word in introducing the debate: integration. I will talk about that, because if we are to fulfil the potential of the sector, which we need to do, it needs to be integrated. We have heard other important words too. We have heard about “pharmacy first” and also the phrase “wellbeing hub”, which I think sums up where we want to be in time. I will try to address many of the points made in all parts of the Chamber, but I will also set out what the Government are planning. When we boil it down, however, there is a huge amount of agreement about where we need to get to and the direction of travel. We also heard about Scotland, which is not perfect—the Murray review made some points about IT integration in Scotland, which is not yet working as well as it might—but as I have said in the past, I think we have things to learn from Scotland.

Everyone in the Chamber, Government or Opposition, can agree on three things. First, we need to move funding and the profession from a model based principally on dispensing to one based much more on services. Of course it is true that, to an extent, we are already going in that direction, but the funding model is not facilitating that, and it needs to. The Government must address that and take it forward.

Secondly, we all agree that services are a good thing per se, but that they are better if integrated with the primary care pathway much more than has been the case historically, and that is about working much more closely with GPs. I do not agree that employing more clinical pharmacists in GP practices is a “red herring”; it is part of how we bring the professions together, although I accept historically there have been difficulties doing that.

The third thing we all agree on—this must apply to the Opposition as well—is that we need to get value for money for the £2.8 billion that we spend on dispensing around £8 billion-worth of drugs. It is right to look at doing that as efficiently and effectively as possible. For example, the existing funding model encourages clusters to develop. I note that the establishment payment in Scotland is £1,700 per annum—I think I heard that right—while ours is £25,000, which has encouraged clustering, so that NHS money is not being spent on frontline services.

It is worth reminding the House that none of the efficiency changes that we announced before Christmas represents a cut of money going back to Treasury; the money is being reallocated to other areas of the NHS. The impact analysis talks in some detail about how money can potentially be spent more efficiently. In parallel with that, we need to make progress on services. I completely agree with that, and I will talk about the pharmacy integration fund and the Murray report, an important piece of work which my hon. Friend the Member for St Albans talked about and which will inform our policy.

We all agree not only on those three things, but on others. For example, there is a big benefit in diverting activity away from GPs. Various reports have been produced by the sector itself, and the Government accept that up to 30% or 40% of GP appointments could possibly be handled by pharmacists. That is a massive number. If we can achieve that, it will be of great benefit to us all. More can be done in pharmacies, such as medicine reviews and medicine optimisation, let alone how they can help us with the public health agenda, which we have not covered in particular today. A lot could be done with smoking cessation, obesity and sexual health programmes.

[Julie Cooper]

The Minister is contradicting himself. Pharmacists are already planning to reduce the hours that they are available to provide these services—the very services that he tells us he values and wants to see more of. Does he accept that if he persists with the cuts, there will be less of them? Some pharmacies will close, while others will reduce services, and are already planning to cut opening hours and reduce staff.

[David Mowat]

What we are not reducing is the amount of money available for services, as opposed to dispensing. Some pharmacies use part of their dispensing money to provide services on a discretionary and ad hoc basis, but I make this point again: overpaying for dispensing is not a good vehicle for getting more and better services.

I want to talk about some of what is already happening. We have heard about flu jabs this morning—I, too, had a flu jab at a pharmacy—and at the end of last year, we had had more flu jabs in pharmacies by October than we had in all of the previous year. The money available for that and similar service-based allocations has not been affected by the changes we announced. The community pharmacy sector has received £10 million for flu jabs up to the end of October. We want to see more of that happening, and that direction of travel is important.

A number of hon. Members made the point, which I agree with, that the public need to understand that pharmacies represent an important first port of call—it should not always be GPs. The Government can do more to make that clear. When I was preparing for this debate last night, I saw a television advert from NHS England for its “Stay well this winter” campaign. The campaign is running TV and newspaper adverts, and its theme is for people to visit their pharmacy as soon as they feel unwell. The people running the campaign have told us they think the advertising campaign has generated about 1.2 million additional pharmacy visits that would not have happened otherwise. That was a good challenge and we need to do more of that.

We also need to go further with services. There are two approaches. I recommend that anyone interested in this subject—as everyone present clearly is—reads the Murray review, which was produced by the King’s Fund. NHS England commissioned the review to inform it and us on how to spend the integration fund, the budget available to drive services more deeply into the system. I will talk about some aspects of that and about some announcements that I made in October as part of the package we are discussing.

One of the announcements was about urgent or repeat prescriptions. At the moment, NHS 111 gets about 200,000 phone calls a year asking for a further prescription, and those callers are told to see an out-of-hours GP to issue a prescription, which in due course goes to the pharmacy. We are changing that so that people will be directed to a pharmacy immediately. That is a stream of revenue for the pharmacy, which will provide both a consultation, for which it will be paid, and then the drug or prescription, as necessary.

My hon. Friend the Member for St Albans asked whether that scheme would somehow affect a good local scheme in her area. There is no reason why that should be the case. The new scheme is supplementary to anything that might have been commissioned already. It sounds as if her scheme was commissioned by the CCG, and that is good, although it takes us to the fact that things are patchy—different CCGs do different things in different areas, which I will come to. However, that is an example of where we need to be.

Another example is the minor ailments scheme. As I have said, 30% to 40% of GP appointments could be dealt with in pharmacies. Parts of England already have minor ailments schemes, but the service is very patchy and it need not be. It is true that different CCGs and indeed different GPs have different attitudes to such schemes, but NHS England has made a commitment that by March 2018 it will have encouraged all CCGs to be commissioning minor ailment schemes in pharmacies across their patch.

[David Mowat]

Yes. Throughout the country, the number is far more than £5 million—

[Julie Cooper]

Will the Minister give way?

[David Mowat]

If I may answer the previous intervention, I will certainly give way again. I have talked about medicine optimisation and pharmacies doing reviews, in particular in people’s homes, for example, and they are part of that solution. Pharmacists in GP surgeries are part of the solution too, and a way of achieving that—as I said earlier, I do not agree that that is an irrelevancy.

[Julie Cooper]

I thank the Minister for giving way. A highly trained pharmacist, who often has a trusted relationship with his patients in the community, is better placed than any other health professional to lead on saving money on wasted drugs. Patients quite often say in a close conversation when they collect their prescription, “Actually, I’ve not been taking that,” but they quite often do not say that to their GP. The pharmacist will then take it upon themselves to say either, “Actually, do you realise you should be taking this?” or, “Let’s speak to your GP and, effectively, avoid waste.” The pharmacist is best placed to do that.

[David Mowat]

I completely agree. Pharmacists have a big role to play in saving money, and medicines optimisation is very important in that. NHS England has established an integration fund, which will provide £42 million—a significant amount, even in the context of the rebalancing that has occurred—of seed money between now and the end of the next financial year to address just those sorts of things and take that work further.

The Murray review, which was commissioned by Dr Ridge, the chief pharmaceutical officer at NHS England, and published in December, sets out in some detail what we believe the direction of travel should be. Someone asked earlier when the Government will respond to that review. I expect NHS England to respond this month—if I may put that on the record in that way. NHS England will respond, not me, but there is not a lot in the review that is controversial. There are a lot of very good points, many of them about IT integration and the care record. I agree completely that some of the progress we need to make with services involves the ability to both read and write to the summary care record. That will be part of where we have to get to. Frankly, technology is an area in which the NHS could improve. That is true in Scotland—it is true everywhere. I will not spend a lot of time talking about what we need to do, but we could facilitate an awful lot of progress on integration between pharmacy and primary care, and primary care and secondary care, if we had stronger technological and IT solutions.

Colleagues have talked about the need to have more pharmacy involvement in medicines optimisation, and care homes are part of that. Pharmacists could do an awful lot with a more structured approach to care homes. One strand of work that has come out of the integration fund is a care homes taskforce, which is chaired jointly by the Royal Pharmaceutical Society and NHS England and is setting out a direction of travel for doing the sorts of things we have talked about, such as medicines optimisation, in a more structured way in care homes right across the country. There are more than 50,000 qualified pharmacists across our country. There are also 23,000 qualified pharmacy technicians, who are part of this too. The pharmacist profession is not as short as some, and it can and needs to do more to make progress in this area.

One part of the Government’s approach to this whole area that has been mentioned and I do not think enough is made of is the GP forward view. Everyone understands how much pressure GPs are under. There are something like 400 clinical pharmacists working in GP practices. We have committed and budgeted £112 million to increase that to 2,000 clinical pharmacists, many of them dispensing pharmacists. Parts of the community pharmacy network, which we have heard a little about, regard that as potentially in conflict with what they do. I think that is wrong. It is not in conflict; it is a way of breaking down the barriers that I accept there have occasionally been between CCGs and GPs and the pharmacy profession. Those are not in anyone’s interests, and we need to get over them.