Pharmacy First

Lord Markham Excerpts

Tuesday 6th February 2024 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, the holy grail for health policy is a change which improves the service for patients at the same time as reducing the cost of delivering that service. I think we can all see the potential for Pharmacy First to be such a move, if executed well. I have a few questions for the Minister and his answers will help us to understand whether he is on the right path in this grail quest.

First, I understand that there will be a payment per consultation, if the consultation meets criteria that the Government have set, but that there will be a cap on the total budget. Can the Minister explain how this cap will work? Is it per pharmacy or per integrated care board, and what happens if it is exceeded? I do not think that we want people going back to more costly channels simply because of an accounting feature. Secondly, can he explain how the Government will assess value for money in comparing the cost of the Pharmacy First consultations with the estimated savings on the GP and A&E side?

Thirdly, while we are discussing urgent care today, can the Minister also say whether the Government are looking at using pharmacies for approving repeat prescriptions—this was raised by the noble Baroness, Lady Merron—for drugs such as statins that people may be on for many years? The current protocol requires them to go back to their GP for regular reviews. Are there any plans afoot to move some of that medicine review process for long-term conditions also into the Pharmacy First programme?

Can the Minister also explain how instructions will be given to NHS 111 services so that they can properly direct people, in light of Pharmacy First now being an available option? It could make a real difference to the pressure on A&E services if 111 moved appropriate cases over to pharmacies. There are concerns that 111 has a natural tendency to be risk averse and refer people to A&E. If we are going to ask it to refer people now to pharmacies, we need to understand how that shift in direction will take place.

Finally, I have a digital question. It is not the one about the joined-up records that we discussed earlier at Oral Questions, as I am confident that the Minister will tell us that the Government are on track for that. What I want to raise is, even when the pharmacy has issued a prescription and dispensed it, at present what happens is that it will then print it off and post it to the NHS Business Services Authority for payment. This happens with all the prescriptions in the pharmacy system at present. My understanding is that the business services authority will then scan them into its system to make the payments—which seems quite farcical in 2024. So I would be interested to hear from the Minister what plans the Government have to get rid of that piece of the equation or to make it more efficient, so that, when a prescribing process happens electronically, it happens all the way through, to the point at which the pharmacy is reimbursed for the work that it has done.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

I thank both noble Lords for their general welcome of what we are trying to do here. My thoughts on this are that anything that we can do to expand supply should be a good thing in this context.

I will pick up on specific questions. As mentioned, we have not managed to achieve 6,000 additional GPs. To specifically answer the question, we have achieved about 2,799. However, through the use of additional staff, we have managed to achieve 50 million additional appointments in GP settings since 2019, so we actually hit our target on that earlier. I think that demonstrates—this goes back to the Question we had earlier today—that we are trying to use people to the top of their professional skills and supplement that with other skilled people coming in. In terms of output, 50 million appointments are a good example.

We are hoping that this will be a boost to community pharmacies. They are, as I mentioned earlier today, seen as a very important asset. They are often the first line in terms of health in the local community. This is intended to not only enhance the health service in an area but give community pharmacies a necessary boost. I think these figures have been reported, but for the sake of completeness I will say that we have had about 10,000 pharmacies sign up—about 95% of them—so clearly it has been welcomed. In the first three days we have had about 3,000 consultations. In answer to the question about pharmacies being overwhelmed, the early indications are that it has been managed well. You could say that the more business they get is a good thing in terms of their viability. Right now, we feel that it is so far, so good.

On privacy—I will try to group the app and IT questions together a bit later—part of the conditions for being available for Pharmacy First is that a pharmacy has a private treatment area available, so that there will not be privacy issues.

My understanding—I will definitely need to write on this—in terms of UTIs is that it applies only up to the age of 64, as they are less complex in those cases. For instance, as you get older UTIs can be a sign of other comorbidities. I think that is the thinking behind the age of 64, but I will follow that up in writing.

The general point was made by both the noble Baroness, Lady Merron, and the noble Lord, Lord Allan, about trying to expand provision. I would say that this is the first step. We have tried to pick the areas that we think suit the situation well. This gives us the ability to expand as the capability increases. Repeat prescriptions is obviously a very good example, as is managing cases such as hypertension and other similar areas. The direction of travel is very much: let us make sure that this works well and then build on that.

I will answer the questions on IT asked by the noble Lord, Lord Allan, together. The overall thinking on the cap is that we are trying to make sure that this does not run out of control—for want of a better word—in some respects, and that goes back to the value for money question. If you can really prove that it is enhancing and substituting for GP appointments, which we all want to boost the availability of, that has to be a good thing. As ever, you need to try to set up budgets at the beginning to make sure that they are sensible in terms of that control.

To give a sense of direction, it is very much the intention that 111—I include the app and other digital approaches in this—will point a person to the right pathway for them. If we then know that they have one of these seven conditions, such as a simple UTI, sinusitis, or something of that ilk, they will be guided towards Pharmacy First. That is very much the intention. I hope that that in some way answers the question. It is intended that more and more volume is put that way.

In terms of trying to make sure that there is a slicker system with the IT generally, obviously it has to be sensible—for example, not printing things off, and that there is an electronic payment mechanism. My understanding is that that is already occurring in some of the digital areas. Noble Lords will be aware of some of the digital pharmacies, which are paperless the whole way. Those sorts of mechanisms are being set up and it is a matter of expanding them, so that there is a complete digital service. I will come back with more detail on that, but I understand that it is happening.

On the IT systems and the holy grail of making sure that they are all connecting—to give everyone the benefit of our conversation in the Corridor—the idea is that it has to be two-way. You want to make sure that pharmacies have access to doctors’ records. That is not ready today, but it will be in the next few months. Likewise, you want to make sure that whatever the pharmacies do gets updated to GP records. Right now, that will be done by a simple PDF. This is not ideal because it involves a rekeying, but in a matter of weeks, it will update the GP records automatically. The value of that is that, obviously, while Pharmacy First is the forerunner, there are all sorts of circumstances it could be replicated for, whether appointments with physios or any other physician relevant to the patient records. I think that will be a positive when it comes in.

I have tried to answer most of the questions about execution. I think we will all freely admit that, as ever with these things, there is a certain amount of bedding in—it is something that I am glad to see everyone welcomes in principle. I hope that in a few months’ time I will be able to update the House on it; I will be happy to do so. If it is executed well, and we believe that this is working well, we will be looking to extend it to further services.

[Baroness Wyld (Con)]

My Lords, I welcome the initiative. It is very good and has been very well thought out and communicated thus far. I would like to pick up the point made by the noble Baroness, Lady Merron, about women’s health. The point about older women was very well made. Equally, for younger women, on the subject of UTIs, I understand that there have been some very successful pilots, but my noble friend will be aware that for women persistent UTIs can be a symptom of something more serious. Symptoms of more sinister diseases can also mimic UTIs. While I have every faith in pharmacists to be able to refer on where possible, it is also important that women feel empowered to go to their GP if they feel something is not right. Women’s health has too often been pushed on to the back burner or ignored. I would like a bit of reassurance on that.

[Lord Markham (Con)]

My noble friend is absolutely correct to bring that up, and that is why it is quite specific on “simple” UTIs. The devil is in the detail, but the reason behind saying simple UTIs is that so the capacity is there, and you can have a referral to a GP.

In this space I speak from personal experience with my partner. It is much harder these days to get antibiotics for UTIs. We know that this is generally a good thing in terms of antimicrobial resistance, but in many cases, as my wife often says, she knows when she has a UTI—and boy does she need those antibiotics.

Some of the things I have started to see in terms of technology, which is relevant to the question of complexity, include point-of-care devices in surgeries or pharmacies that can detect a UTI very quickly, so that you then know you can give a prescription for antibiotics. That is what we see in terms of the direction of travel.

[Lord Hunt of Kings Heath (Lab)]

My Lords, when I had responsibility for community pharmacy more than 20 years ago, one of the schemes we instituted was incentivisation for private consulting rooms and spaces. I wholly endorse what my noble friend Lady Merron said about the importance of this, and the noble Baroness’s intervention reinforces this. It sounds as if most community pharmacies have some kind of private area, but they are not always as good, secure or private as they ought to be. So I very much hope that the incentive that I hear the noble Lord has built into the scheme will actually lead to ensuring that patients have confidentiality, which is really important here.

On the cap, I understand the need for probity and making sure that there are no perverse incentives to overcount, but it would be a bit of a disaster if, nine months into the financial year, a very good community pharmacy ran out of its allocated funding. What would happen? Will integrated care boards at the local level have some discretion to come in at that point to ensure that that service can continue?

On integrated care boards, some clinical commissioning groups were very poor at getting community pharmacy around the table. It always amazed me that, in their winter planning, they seemed to forget the need to have community pharmacies as equal partners. Can the Minister assure me that, when this programme is taken forward, integrated care boards will be clearly told that they are expected to treat community pharmacies as important partners in this and in planning for winter, which, as the noble Lord knows, continues for much of the year?

[Lord Markham (Con)]

I thank the noble Lord and will answer his questions in reverse. On getting the ICBs around the table, I absolutely agree. This is seen as a key part of those initiatives and handling those pressures. Generally, going back to privacy, I would expect to see, as ever with these things, some pharmacies that become very good and set up really nice areas, with a lot of expertise. I am sure they will push ahead. I am making this up, to be honest—this is not policy—but I would not be surprised if it started off with a base level of ones that can do only the seven, with others that are more skilled and show that they can manage more things, such as hypertension. There will be some very successful ones. On the cap, it would be perverse if those really successful ones suddenly hit the buffers, so to speak. As I understand it, the cap looks at this much more in terms of a global presence. In the department as a whole and the Treasury, we are going into this with a budget in mind and with the appropriate safeguards. But, going back to the value for money question, overspending is actually probably good news because it shows that it is working.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my role as chair of the Bevan Commission in Wales. Through the Bevan exemplars, we have supported projects with extended roles for pharmacists. That included a project on urinary tract infection treatment in remote areas, which was very successful in a farming community.

My questions relate to the way in which this will be evaluated, because this project and the rollout sounds as if they are starting off well, but some difficulties may be encountered. One may be in appropriately diagnosing something such as a sore throat when it might be glandular fever. If you give the wrong antibiotics, there could be quite a nasty reaction. But equally important—in fact, often more important—are drug interactions overall. If the pharmacist does not have a list of the medications that a person is on, there is a real risk of drug interactions. Patients often cannot remember the names of things they are taking, particularly when they have multiple comorbidities. Drug interactions can be a really big problem to manage, so I would like to know how this will be evaluated and how adverse events, such as drug interactions that had not been picked up, will be collated centrally and notified.

My other question relates to the programme we developed in Wales. I declare that I am a vice-president of Marie Curie, which has the “Daffodil Standards” for community pharmacy. Our eight standards for community pharmacists have developed the concept of a pharmacy champion for palliative and end-of-life care, to make sure that medication is available and held in stock in a format that the patient can take. This is also linked to paramedics who are trained to administer medication at home, to families being trained to administer medication, and to pharmacists themselves undertaking individual medicines reviews to see what can be discontinued as well as what can be continued or how doses should be affected. Although we start off with this list, my interest in palliative and end-of-life care obviously means that I would like to see these Marie Curie “Daffodil Standards” adapted much more widely, because we know perfectly well that out-of-hours access to medication can be a real problem for families looking after people at home.

[Lord Markham (Con)]

I thank the noble Baroness. Key to her first point on drug use is obviously the functionality to be able to see the whole patient record— I talked about accessing that earlier. At the same time, the plan for the data flow is to look at what is being prescribed by the pharmacies—before the team gets on my back, I will say that “prescribe” is not quite the right word, because it is patient guidance and they are not formally prescribing. What is issued will go through the same data flow as for GP surgeries so that we can generally measure whether we think pharmacy X is overprescribing—or oversupplying—a certain type of drug versus a GP surgery. The idea is that that will be monitored in exactly the same way. Generally, on the overall experience of Pharmacy First, we commissioned the National Institute for Health and Care Research to review that to make sure it is done.

If I understood correctly, the question behind the palliative care point is, as we said about the other services: can we see them extending more, particularly in terms of out-of-hours use? The beauty of all this—there are things we can learn from the services that Wales and Scotland have introduced—is that, once the principle is established and there is a track record of it working well, there will be all sorts of opportunities such as these to extend it based on capability and, sometimes, convenience, with matters such as out-of-hours care.

[Viscount Waverley (CB)]

My Lords, as time is on our side, I will address, if I may, an issue which may or may not be totally relevant to the subject before us. I apologise to the House if it is not, but it does involve pharmacies. Before I venture forth, I offer the utmost fullest support for the principle of pharmacies playing a critical role in the whole system of patient care. My personal experience is absolutely excellent and that pharmacies provide a thoroughly professional service.

I will address a concern around the cost of purchasing non-medical equipment from pharmacies; it may also have relevance to the cost of living challenges. I went into a pharmacy recently and was charged £23.50 for a packet of four Gillette razor blades—shock horror. Of course, I needed them, and I paid, but I thought it was exorbitant, so I called the wholesaler to ask what was its cost of the same packet. It was £6 to £8. I recognise that pharmacies are a private sector set-up and can charge what they wish, but is there any aspect in this Statement that is relevant to the charges that pharmacies pay? I say this perhaps in support of the point of the noble Lord, Lord Hunt, about having facilities in pharmacies. Of course, they need funds, and pay rent and all the rest for all of the types of facilities that are required, but is there any relevance in relation to the costs that these people can charge? It is no wonder we have a cost of living crisis if people are having to pay those sorts of exorbitant prices.

[Lord Markham (Con)]

My understanding is that what we are really talking about here are the seven areas where they are allowed to supply treatments and courses of drugs. I do not think there is any read-across to other areas such as the pricing of medical instruments. I do not think that will help in this instance, but when I write round on the detail, I will make sure that this is clarified. Right now, I do not think that is envisaged by these measures.

[Viscount Waverley (CB)]

I never anticipated it was; I just thought it was relevant to the general circumstances of what people are being charged in purchasing from pharmacies.

[Lord Markham (Con)]

Again, it goes back to the point that, generally, we all agree that pharmacies offer an important service. Obviously, one would hope that they would be responsible; the vast majority of them are and there will not be such—predatory pricing probably is not the right word—hyper-pricing behaviour. Clearly, where those things do happen, I do not think any of us would support it. That is not the sort of thing we would want to be happening in any retail location, let alone one which is providing vital services.