Big on presentation and short on detail, health secretary Sajid Javid’s roll-out of the £250m ‘winter access fund’ last week nevertheless gave the clearest indication yet of the government’s strategy to solve the crisis in primary care: coerce and mislead, and talk up pharmacies instead.
As the primary care sector struggles with a shortfall of 6,000 GPs and 26,000 nurses and receptionists, the government’s response – outlined in the NHS document ‘Our plan for improving access for patients and supporting general practice’ – is a £250m ‘winter access fund’, worth just £33,000 per surgery.
Sold to the public as a way to “help patients with urgent care needs to get seen when they need to, on the same day, taking account of their preferences” – in effect mimicking the sales pitch of a telehealth service – the awarding of this cash, however, requires primary care networks (PCNs) to use the NHS Community Pharmacist Consultation Service (CPCS), overseen by the independent Pharmaceutical Services Negotiating Committee (PSNC).
The strategy also suggests that pharmacists joining up with PCNs will now “automatically be trained to prescribe”, adding that NHS England is continuing “to increase the role of community pharmacists in delivering appropriate services”. The move was reported in the Daily Mail as being “likely to include handing [pharmacists] the power to prescribe a number of medicines which are currently the sole preserve of doctors”.
This gives the misleading impression that pharmacists have up until now been unable to prescribe. But they can, and have been doing so since 2006.
Guidance from government agency the National Institute for Health Research suggests pharmacists – along with nurses, midwives, dentists, optometrists, podiatrists, physiotherapists and therapeutic radiographers – can already become ‘independent prescribers’, meaning they can prescribe any drug within their competency, including controlled drugs.
Documentation supporting the health secretary’s strategy, meanwhile, also includes plans to “embed electronic fit notes in hospital systems”, with the Mail apparently suggesting that hospital doctors writing more prescriptions is part of the new bargain too. But the implied suggestion that hospital doctors don’t already do much prescription writing is again misleading.
As NHS hospital consultant Dr David Oliver told The Lowdown last week, “The standard NHS contract with providers already makes it clear that hospital doctors should do sick notes and prescriptions, and also follow up on test results. This is all in the public domain and negotiated between NHS England, the BMA and other key organisations – and this has been the case for a good while now.”
Continuing his push to promote the role of pharmacies, the health secretary also mooted the idea of a national version of the Pharmacy First marketing programme, currently being piloted by local CCGs across England.
Such a move would certainly help boost the profile of the sector, but there are other behind-the-scenes initiatives in the pipeline aiming to further embed pharmacies within the NHS.
The PSNC is currently lobbying for pharmacy representation on the NHS’ new Integrated Care Boards, alongside GPs. It has also reported that the £250m winter access fund is not going directly to GP practices but is being distributed via local CCGs, noting an opportunity to bid for funding on behalf of the sector.
Meanwhile, last month (September) the All-Party Parliamentary Pharmacy Group (APPG) launched an inquiry, supported by the PSNC, into the future of pharmacy in the wake of the pandemic. It is seeking views from the pharmacy sector on a range of issues, including “how pharmacy can be better integrated into NHS care pathways”.
Pharmacies undoubtedly play a useful role in public health programmes. High street chains Boots, Lloyds, Superdrug and Well are all notably taking part in the current flu vaccination campaign, and at the time of writing Boots and Lloyds were also involved in the covid booster jab programme.
But, at the same time, pharmacies have done very well out of a public health crisis. Accountancy group UHY Hacker Young has noted that the number of mergers and acquisitions deals in the UK pharmacy sector has risen 26 per cent in the last year, thanks largely to pharmacies being one of few sectors to benefit from increased customer demand during the pandemic. It also noted private equity buyers were showing increased interest in the sector, with the US owner of Lloyds Pharmacy, McKesson Corporation, having recently been in talks with three prospective bidders for the sale of its UK business.
The pandemic has certainly provided a boost to retail pharmacy chains’ ventures in the telehealth sector – such as Lloyds Pharmacy’s Video GP and Boots’ recently launched Online Doctor services, both able to issue prescriptions – just as cash- and resource- starved GP surgeries continue to struggle. Boots has said it is looking to further expand its online services soon, starting with mental health.
In a parallel bricks-and-mortar move by the retailer, the Sun reported earlier this month that Boots is to offer £15 GP-style health face-to-face appointments for minor ailments. The company’s chief executive Seb James told the newspaper, “Rather than wait two weeks to see a GP, people can [now] get immediate diagnosis, treatment and medication for the price of a Nando’s.”
An indication of where Boots might be heading in the UK with its pharmacy operations can be gleaned from the latest move of its US owner Walgreens Boots Alliance (WBA). This month WBA spent $5.2bn on increasing its stake in primary care network VillageMD to 63 percent, in the process becoming the first pharmacy chain in the US to offer full-service primary care practices with physicians and pharmacists co-located in its retail outlets.
However, some elements of US culture don’t always sit well in a UK context. In 2017 Boots was criticised after telling the British Pregnancy Advisory Service (BPAS) it was simply avoiding “incentivising inappropriate use” by refusing to reduce the cost of its Levonelle emergency morning-after pills. And earlier this year BBC News noted cases where individual pharmacists have refused to give out the morning-after pill because of their religious beliefs.
How developments like these play out long term remains to be seen, but those assuming general practice will remain the bedrock of the NHS could be in for a shock, as pharmacies – which are as much profit-driven enterprises as they are community services – gradually assume the role of primary care provision while subtly undermining the concept of ‘free at the point of access’.
An enhanced ability for pharmacists to write as well as dispense prescriptions, alongside the new obligation for GPs to, in effect, push business their way at the same time – as Javid is proposing – will undoubtedly prove a nice little earner for pharmacies. It could also encourage more US retailers to consider entering the UK market, in much the same way as Centene Corporation and Operose Health saw value in buying London primary care service provider AT Medics earlier this year.
But Javid’s CPCS initiative interestingly coincides with a proposal by the Department of Health & Social Care (DHSC), which he oversees, to scrap free prescription charges for people aged between 60 and 66. This move, seen by some as representing a “tax on the sick”, could adversely affect the health of more than two million UK citizens if implemented, according to Age UK and the DHSC’s own impact assessment. Then again, it could also drive others affected by the move to consider signing up to services like Boots’ Online Doctor and Lloyds’ VideoGP.
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