
Image: National Pharmacy Association
The future of 3,000 community pharmacies hangs in the balance as a round of cuts starts to be imposed on them this month, despite earlier hints of compromise.
The cutbacks to key pharmacy service subsidies – part of a 12% reduction in overall money allocated to the sector - were first announced in December 2015 and a row has been underway ever since. In September, minister David Mowat appeared to back away from the cuts. But the following month the reductions were confirmed.
The cuts coincide with longer-term concerns over a planned online centralisation or ‘Amazonisation’ of high-street pharmacy care in England.
Perplexingly, there appears to be no way of
knowing which pharmacies will be forced
to close,
nor what the government’s rationale for the distribution of the
reduced public pharmacy spending
is. Rural
practices are set to be hit particularly hard.
“The
government doesn’t know the impact of its own impact
assessment”
Under
the new funding measures, the Establishment Payment – a lump sum
that covers most basic pharmacy services - will be phased out over
next 4 years, with a 20% cut over the coming year. Along with a
Professional Fee, a Practise Payment and a Repeat Dispensing Fee
pharmacies receive, the Establishment Payment is being merged into
one Single
Activity Fee.
An accompanying Quality
Payments
scheme, which will be included in the 2017/2018 Community Pharmacy
Framework, is very similar in nature to the QOF
payments that currently exist for GPs. The payments reward ‘high
volume’ practices (particularly monopolies and chains like Boots),
since they encourage box-ticking and introduce a regulatory burden on
smaller pharmacies where there is less of a paperwork-processing
apparatus in place. Independent practices will be hardest hit.
The
Department of Health has said it wants to avoid “clusters”
(pharmacies within 10 minutes walk of each other). But Kieran Eason,
whose Tamworth practice is one of many that could lose out as a
result of the new measures, says the government is failing to look at
why there might be a high number or concentration of pharmacies in
certain areas of the country. “It could, for example, be down to
serving different patient groups” he points out.
Sue
Sharpe, head of the Pharmaceutical Services Negotiating Committee,
has said the government policy is “not
being driven by evidence”.
A political storm has been brewing - Norman Lamb called the cuts a “false economy”, and Labour MPs have been vocal. Shadow Health Secretary Jon Ashworth berated Mowat for his weak defence of the cuts in Parliament and warned that some communities risk being left without a pharmacy.
The Department of Health’s initial letter to Sharpe in December 2015 was full of claims that we now know to be misleading – like the now debunked £10 billion spending increase and the supposed push for a 7-day service which in fact already exists – claims that merely attempted to sugar-coat its cut announcement without offering any clear rationale behind the proposals other than “efficiency savings”.
Pharmacists like Eason are unconvinced by the recent impact assessment. “They don’t know the [real] impact”, he comments. The impression is of a group of civil servants pushing through with the measures to meet a financial target (£22 billion is the overall figure) set by the Treasury, regardless of consequences.
The
cuts are front-loaded into the first quarter of 2017. So there’s
the possibility of a cash flow problem in the immediate short term as
pharmacies struggle to pay their suppliers.
The National
Pharmacy Association has
also argued the
cuts
will compound winter
pressures
the NHS faces each year. This is arguably a situation the government
could have foreseen, and could have better prepared for, since they’ve
been planning these new measures for over a year.
Costs
of the move towards chains and centralised online distribution
Aside
from cuts, the market is extending its presence in pharmacy care
through a variety of online distribution services. Sources close to
Jeremy Hunt told the Times that the Health Secretary had “spoken
privately of his desire to ‘Amazonise’ our pharmacies”.
The alternative, a hub-and-spoke dispensing model, seems to have been put on hold, leaving us with an Amazon-style system – whereby prescriptions would be ordered through a centralised online dispensing mechanism and delivered to patients' homes.
Such a system, crucially, removes the various human and social aspects of care carried out by community pharmacies. Instead the government are referring people to NHS 111, the already over-stretched non-emergency helpline, without explaining how they plan to fund the increased demand on that service that would result.
The worst case scenario is that people simply don’t call, and miss their prescriptions. “The [government] predictions are ridiculous and unrealistic...just window-dressing to mask the negative impact of the cuts”, comments Eason.
There are concerns this online
model could pose a number of risks to customers, particularly given
the fact that most patients using community pharmacy are elderly.
There are also privacy risks for customers ordering prescriptions
through an online distribution service – as illustrated by the
information-selling
case that Pharmacy 2U found itself embroiled in last
year.
Ramifications
and full extent of cutbacks’ impact still not known
The
All Party Pharmacy Group has launched an inquiry into the
government’s reforms and their impact on community pharmacies and
patient services, including the Integration
Fund
and the Minor
Ailments Service.
The group
has already called for “further investment in community pharmacies
to allow them to provide more health services and ease the burden on
GP surgeries and hospitals”,
in the words of its chair, Sir Kevin Barron.
The
cross-party group of MPs is still awaiting
the findings of the
soon-to-be-published 2016/2017 King’s Fund review of community
pharmacy.
There’s huge professional and public
opposition to the reductions, as evidenced by an online petition
which garnered over 2.2 million signatories earlier this year.
This latest funding measure represents yet another blow to the NHS as a public healthcare provider in England, at the end of a year which has seen: the forcing through of the widely opposed, unsafe junior doctor contracts; the Southern Health scandal; a growth and continuation of the existing corporate, market-driven culture at the heart of the NHS; and, most recently, a £700m sale of contracts to Virgin while media and public attention was fixed on the outcome of the US Presidential Election.
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