Community Pharmacies

Philippa Whitford Excerpts

Wednesday 2nd November 2016 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The Minister kindly referred to the system in Scotland, which has been running for 10 years since we passed the Smoking, Health and Social Care (Scotland) Act 2005. It took time to introduce the new system, but now all pharmacies in Scotland are community pharmacies, meaning that they all provide services. They do not get a big payment merely for existing—they receive a quite tiny £1,730—but they do get payments based on needs that reflect a population’s age, vulnerability and deprivation, so those things are taken into account in their global funding. That funding is due to go up 1.2% in Scotland while there is talk of a reduction of 4% here.

The services provided have been referred to as the minor ailment scheme. Many pharmacies in England make provision under that scheme, but it is not a national system. In Scotland, the scheme is national and such services must be provided. One issue is that the pharmacies have to invest. They have to build a consulting room and change their building so that people can be seen privately when their minor ailment is diagnosed. They work to protocol for a whole list of ailments that they can diagnose and have the ability to treat. The ailments are minor things that many people would experience, and the approach avoids their having to go to a GP.

[Stephen Pound (Ealing North) (Lab)]

The hon. Lady makes an incredibly important point. People who go into a community pharmacy today will see a special treatment room where they can get phlebotomy, advice on blood pressure and all sorts of other things. Is it not perverse, cruel and utterly irrational to say to a group of professionals, who have done all this work to change the way they deliver their services, “Now we are finished with you. Out you go. You’ve done your bit. We are going to put you out and close down your pharmacy”?

[Dr Whitford]

I agree with the Government about looking for more services, but this is not the way to work with the profession, given that they want those in it to do more work and to work differently. Sadly, during my time in the House, we have repeatedly seen the Government not sitting down with a profession and saying, “Why not look for where savings can be made?”, but simply making a cut.

[Karin Smyth (Bristol South) (Lab)]

I was going to intervene on the Minister to follow up the point made by the Chair of the Health Committee. We are looking at bottom-up planning in England for the first time for a number of years with the sustainability and transformation plan process, so this is completely the wrong time to be making these irrational and random cuts.

[Dr Whitford]

We recently debated STPs and the potential they provide. The danger is that at the moment we are seeing finance-centred care, instead of patient-centred care. Going back to place-based planning, which is what we have kept in Scotland, where we still have health boards, means that we can look at integrating services, and pharmacies definitely need to be part of that. They have the potential to be a significant front-line player.

[Maria Caulfield (Lewes) (Con)]

I am interested in the experience in Scotland, although we do not have the same system in England. What does the hon. Lady think about moving pharmacists into GP surgeries? I think that it is a mistake. I would much prefer the approach that is being taken in Scotland, where pharmacies are expanding by having consulting rooms of their own.

[Dr Whitford]

Scotland actually has both. We do have pharmacists who are in a consulting room within a practice, and our Government have put £85 million into taking on an additional 140 pharmacists who work in primary care with GPs. We are not, as has been done in the past, saying, “Everyone on drug A must change to drug B because it is cheaper,” without giving any thought to how that affects the patient. We are consulting patients, who are often on 10 or 15 medications, all of which interact and have different side effects, and then rationalising that and giving the patient advice. We are therefore providing a clinical service rather than just a changeover service.

Our community pharmacy system has been running for 10 years, so it is quite mature. Patients register with a pharmacist in the same way as they register with a GP. The aim is for all people to be registered with whomever they consider their local pharmacist to be, as that means that they can access minor ailment treatment. It also means that people who are on chronic medication have a chronic medication service, with their prescription sent electronically to the pharmacy, which then keeps track of when it is due and therefore ensures that patients do not run out of medication. The pharmacies also provide an acute medication service for people who have not signed up to the other service but suddenly find they have no tablets, as they had not thought to re-order them with their GP. If they are regulars at the pharmacy, a single round of drugs can be prescribed for them there so that they do not have a gap in their treatment. The important thing is that our vision is to have all our pharmacists as prescribers by 2023, and to have our public registered with pharmacists by 2020.

[Mr Jim Cunningham (Coventry South) (Lab)]

The hon. Lady makes two important points: this move is cuts-led, rather than well planned; and just as communities rely on their doctor, they rely on the facilities at their pharmacy. That is particularly true of elderly people and those with disabilities, who may have to travel miles, depending on where the pharmacy is.

[Dr Whitford]

It is crucial that the service covers all areas, including those that are deprived and those that do not have good public transport. Distance is not everything; this is also about how people travel that distance. In many places, the distance involved might not be that great, but there simply may not be a bus going in the required direction.

[Catherine McKinnell]

I wanted to make this point to the Minister: the closure of community pharmacies will clearly lead to a poorer service, a loss of patient choice and poorer health outcomes for those in more deprived parts of the country. Is this not just another example of Government short-term cuts that will cost us more in the long term?

[Dr Whitford]

If this is introduced badly, the cost will be greater in the long term. When the Minister talks about a more service-based approach, I think that he aspires to something more like the Scottish model, which I would commend. I just feel that this is being done “backside forward”.

[Anna Turley (Redcar) (Lab/Co-op)]

rose—

[Dr Whitford]

I need to make a bit of progress.

We need to design the services with the people who work in them. Some 18% of Scotland’s population—nearly 1 million people—are registered with and do access the minor ailment service, which takes pressure off accident and emergency, because there is availability out of hours, and GPs. The fourth service that we have is the public health service, with 70% of all smoking cessation work in primary care being carried out in our community pharmacies. These four services together—minor ailments, chronic medication, acute medication and public health—represent a huge breadth of service for a community. It is important that pharmacies in England that are currently just retail and dispensing pharmacies are encouraged to go in that direction, because it brings benefit for the NHS.

My biggest concern is the random nature of how this process might develop. If the Government simply cut and let the dice fall where they will, the problem is that they will not end up with an integrated service. Scotland still has health boards, so if a community pharmacy is to open there, an application needs to be made to the health board. When the project started, the boards decided which places got to become community pharmacies, and they decide whether there is a need to open a new community pharmacy. The biggest mistake in this scheme is its randomness.

One issue raised by the hon. Member for South West Wiltshire (Dr Murrison) was the profits made when drugs are sold on. The Government could look at the vertically integrated wholesalers—the big chains. In the mid-2000s, they were not considered. The Government do not know how much profit they make or where that profit is made, and the system is totally unregulated. These chains control about 40% of the pharmacy market. One of the biggest chains, Walgreens Boots Alliance, has declared profits of almost £1 billion, yet it has somehow been able to reduce its tax bill by more than £1 billion in this country. We are talking about people who are make almost half their profit from taxpayers yet do not pay their full share of tax. I absolutely agree that under this proposal the big chains will survive and the small, independent, very community-based pharmacies will be lost.

[Neil Coyle]

The Minister accused those who highlight concerns of “scaremongering”. Atul, who runs St George’s pharmacy at the Elephant and Castle in my constituency, says:

“We may survive the first set of”—

in-year—

“cuts by compromising on our services. But the second set of cuts next April will most definitely place us at a real risk of closure.”

Does the hon. Lady agree with Atul that it is right for us to highlight our concerns, especially in constituencies such as mine, where we face losing 18 community pharmacies?

[Dr Whitford]

Losing that many pharmacies in any area would be a disaster. This is a bit like groundhog day, because this is our third discussion on this topic in as many weeks. The Minister said that there absolutely would be protection, but the pharmacy access scheme still largely comes down to the amount of dispensing that is done and the distances. It does not take account of which pharmacies are providing a good service, which ones are set up to provide a good service and how to encourage others to develop. This is what is completely wrong in the Government’s approach. They are just slicing money off and leaving individual businesses to decide whether they think they will be profitable. The danger would be that we get a whole lot of pharmacies deciding to sell out and walk, instead of someone saying for a particular area, “Eighteen is too many”—especially if they are all around one town square—“so which ones are best able to develop a service? Let them bid for it and let them be inspected, and let’s see how they take it forward.”

The Government could make a lot of savings by addressing the wholesalers. In Scotland, we have margin sharing, which means that a price control group looks at the profit that is made at various stages, and some of it has to be shared back. We do have people who are trading on the open market and moving drugs around, especially in the big chains. As we heard earlier, we would get a better result by sitting down with the profession and designing a service. STPs could provide the model within which to look at how many community pharmacies there should be and where they should be, and then it would be a case of working backwards.

The danger of the Government’s approach is that it is the wrong way round. Just calling something an “efficiency cut” does not make it efficient, and the danger is that we just slash something and it falls over. The pharmacy access scheme is not enough of a protection or of an intervention. There needs to be planning. I commend the idea of a proper services-based pharmacy system, but the aspiration should be not just that a few pharmacies choose to do it and others do not. It should be that a patient who walks into a community pharmacy will know what services they can get, and we should aim to have that right across the country.

[Several hon. Members rose—]

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[Oliver Dowden]

I thank my hon. Friend for that intervention. Equally, many such pharmacies do not provide any of the wider community health benefits. In essence, they are just dispensing services.

[Dr Philippa Whitford]

Is it not estimated, however, that those will be the ones that survive, purely because they are big, while the small, high-service pharmacies in communities are more vulnerable?

[Oliver Dowden]

That is precisely the point that I am coming to. As we proceed with these reforms, hon. Members need to recognise that we will need further savings in this area. I am not attacking large retailers because of their size; it is because of the lack of such wider provisions. We need to look at ways of securing further savings from them which we can plough back into the community pharmacies that are providing the services on which all our constituents rely. I completely accept that pharmacies that are purely dispensing services are very inefficient as such. They are highly labour-intensive; it is just a very expensive way of delivering drugs. We need to identify ways in which we can bifurcate the two different types of providers.

I pay tribute to what the Minister has announced so far. He clearly demonstrates an understanding of the situation, as we have seen in relation to the protection of key local pharmacies through the community access scheme. For example, in my constituency, the services in places such as Elstree and Shenley, where we have small, rural communities, often with an elderly population, will be protected. Equally, the quality payment scheme recognises some of these wider community benefits.

However, I urge the Minister to do more in that area. Let me make two brief suggestions. First, we need more detailed recording of the sorts of services that are provided by pharmacies which take pressure off the NHS. As I understand it, there is no systematic way in which these additional benefits are recorded, and we are all working on the basis of estimates. We could have a system whereby the community pharmacies systematically recorded the benefit that they provided, and then they could be better rewarded for those benefits. At the same time, there would be a means by which we could penalise, or find further cuts from, the pharmacies that did not provide those additional services.

Secondly, the hon. Member for Central Ayrshire (Dr Whitford) rightly commented on the common ailments scheme that operates in Scotland. The Minister indicated that the Government are moving down that route. I urge the Government to go further on this. There is absolutely no reason why patients suffering from things such as common cold and flu symptoms or head lice could not be referred directly from their GPs to pharmacies, thereby saving money for GPs and providing additional income for those pharmacies.

I support the overall direction of reform, but as the Government proceed with these reforms, they could do with engaging more in looking at ways of supporting what is best in community pharmacies while providing further savings from the services that do not provide them.

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[Maggie Throup (Erewash) (Con)]

As many hon. Members have already described, our community pharmacies play a vital role in all our communities. When my mum was seriously ill and housebound, her local pharmacist and all his staff were amazing. Nothing was too much trouble, whether it was changing her medicines at the last minute and delivering them to her home, or offering to deliver things like toothpaste and loo rolls at the same time. That is what community pharmacists are all about—being at the centre of the community, wherever they are.

Being part of the local community is even more important in rural areas, especially for the elderly who are often housebound, or have limited access to cars and so rely on public transport. That is why I welcome the pharmacy access scheme that the Minister has put in place. It should safeguard those pharmacies that are more than a mile apart and, more importantly, protect their patients. The Minister has gone further by adding in areas with high health needs. That must be welcomed, but I would like more specific information to help to reassure pharmacies in my constituency.

We all know that pharmacists can and want to do more. It is imperative that every community pharmacy across the country plays its part in providing first-class healthcare outside the hospital setting. Pharmacists are highly trained professionals with a wealth of knowledge that must be used to its fullest. As we hear time and again, our GPs are under a great deal of pressure. Our pharmacists are a group of professionals who can and do shoulder some of that workload. To name just a few of the services they can provide, they can give flu jabs, test cholesterol, monitor warfarin and check blood pressure. There is no reason why they cannot carry out other simple tests, such as point of care C-reactive protein tests to distinguish between viral and bacterial infections, and so play their role in combating antimicrobial resistance.

I have a request for the Minister. He should be more ambitious with the timescale for roll-out of the minor ailments service. We have already heard from the hon. Member for Central Ayrshire (Dr Whitford) about just how successful that service is in Scotland. We must combat any barriers that the CCGs put forward, as my hon. Friend the Member for Amber Valley (Nigel Mills) suggested.

The 18% increase in the number of pharmacies over the past 10 years has in many instances led to clusters of three or more pharmacies within just one location. Each gets a guaranteed payment of £25,000 every year regardless of the quality of service they offer, the number of prescriptions they process or whether increased capacity in the area was needed when they actually opened. I am sure many of my constituents will think that is wrong and wonder whether it is the right way to spend taxpayers’ money.

[Dr Philippa Whitford]

Does the hon. Lady recognise that pharmacies were allowed to open simply because they were willing to be open for 100 hours? The growth was random, and my concern is that this cut is random. Planning is the issue.

[Maggie Throup]

I completely agree that growth has not been controlled. We need to go back a number of years to learn from what happened and ensure it does not happen again. We also need to ensure that we put the right reforms in place now.

It is important that the £25,000, just for opening the doors, is not offered to other retail stores on the high street. It is vital we get the best possible deal for the taxpayer and the patient. The patient must be at the heart of everything. We must also remember that every pound saved by these changes will be invested back into the NHS. We need to get the important message out that, whether it is for cancer treatment or other life-saving treatment, every penny counts.

If the proposed reforms reward quality, pay pharmacists for their value added services and fully embed community pharmacists into the urgent care pathway, they will be welcome. However, we need to ensure they do what they are intended to do, and that we do not, as the hon. Member for Central Ayrshire said, end up with what we have now.