Time to cut back on services? A look at the NPA's work to rule vote

With the NPA asking its member pharmacies to consider reducing services to the minimum required by their NHS contracts, is work-to-rule a necessary last resort – or an unwanted distraction? By Saša Janković

At the end of September the National Pharmacy Association (NPA) announced it would “ballot” its 6,000 members on a potential work-to-rule action for the first time in its 103-year history. 

With 1,500 pharmacies having closed over the past decade and many more struggling to remain open, the move came after two separate days of action organised by the NPA to highlight years of rising pressures on community pharmacies, compounded by a 40% real terms funding cut over the past 10 years and increasing workloads.

A formal notice was sent to members asking if they would reduce services and put NHS leaders on notice that they will cut their hours to contract minimums and withdraw free deliveries or free medicine dispensing packs if the financial situation for pharmacies does not improve.

It also asked pharmacies if they would boycott data collection beyond that required in their contract and consider serving notice on a range of locally contracted services, negotiated directly with local authorities. 

The most recent five-year contract for pharmacies in England expired in April, but nearly halfway through this current financial year, no funding offer for this year has been made public and no discussions have been opened on a longer term settlement for the pharmacy sector. 

As a result, the NPA is calling for a £1.3 billion funding increase in England to plug the financial black hole facing community pharmacies, with Paul Rees, chief executive of the NPA, saying of the vote: “It pains us to take this step but pharmacies are being pushed to the brink by a decade of real terms cuts that has slashed 40% from their funding.

"We desperately want to work with Wes Streeting and the new government to unleash the vast potential of pharmacies to deliver the better health in the community that we all want.

"But despite big settlements for junior doctors and others since the election there is no sign, as yet, of an end to the chronic real terms cuts that are literally driving dedicated healthcare professionals in pharmacies out of business.”

The vote will be open for responses for six weeks, with the NPA saying any action supported by a majority of pharmacies could take place before Christmas. 

However a delay would not be unsurprising – especially since Secretary of State for Health and Social Care Wes Streeting criticised the NPA’s “threats of collective action” at the Labour Party Annual Conference in September, saying it would “put pressure” on other parts of the healthcare system. Calling it an “unhelpful degree of sabre rattling” by the NPA, Streeting added: “The fact is collective action, whether by GPs or pharmacists, will harm patients and make the relationship with patients worse.”

French strike action

Across the Channel, pharmacists in France held a one-day strike in May in protest against the French government’s handling of medicine shortages, online pharmacy proposals and an economic settlement that unions claimed was driving the rapid rise in permanent closures – the first industrial action staged by the sector since 2014.

At least two unions – the USPO and the FSPF – appeared to be involved in organising the action, with USPO director general Jérôme Koenig telling P3pharmacy at the time that pharmacists were spending up to 12 hours per week dealing with shortages.

He claimed government officials had refused to engage with the sector’s proposed solutions around supply chain transparency and enhanced substitution powers for pharmacists, and that up to 40 pharmacies were closing each month amid economic difficulties, endangering the health of local communities. 

UK community pharmacies have not taken part in industrial action in recent memory.The closest they got was in early 2020, when community pharmacists in Northern Ireland voted overwhelmingly in favour of industrial action over a long-running funding dispute with the Department of Health.

However this was called off due to the Covid-19 emergency. Meanwhile, pharmacies in England refused to roll out new services and service expansions last year over concerns about the financial strain they would place on the sector’s core activities, a stance that was later dropped following successful talks. 

Work-to-rule action is not a new concept within other healthcare professions. GPs officially began work-to-rule action on 1 August 2024, following a ballot by the British Medical Association, in which 98 per cent of members voted for action “to protect general practice”.

GPC England – the representative body for general practitioners in England and part of the General Practitioners Committee (GPC) – said it would “not recommend which action(s) practices take” and called the initiative “a marathon, not a sprint”.

Among other strategies, it suggested limiting daily patient contacts, serving notice on voluntary services, switching off Medicines Optimisation Software, and – in a move which would have a knock-on effect on community pharmacies’ delivery of Pharmacy First – switching off the GPConnect Update Record functionality.

As a result, Community Pharmacy England (CPE) advised pharmacy owners that in order to maintain the safety of their services, with the safe supply of medicines a key priority, if patient demand for services and advice outstripped their capacity to provide it they may need to activate part of their business continuity plan.

For example, CPE said: “That may mean you decide you must prioritise all staff time to focus on the dispensing service and dealing with patients referred by NHS 111 or general practices, rather than people walking in or contacting the pharmacy for help and advice”.

Commenting at the time, CPE chief executive Janet Morrison said: “GP teams are not the only people in primary care who are exhausted, overworked and struggling to make ends meet... We will continue to push the new government and NHS England to address the underfunding of pharmacy services.”

PDA concerns 

In light of the NPA’s vote, a spokesperson for CPE said of the negotiator’s stance that: “Of course, pharmacy owners can choose which campaigns and activities they wish to actively support.”

However, the Pharmacists’ Defence Association (PDA) says it has “noted with interest” the NPA’s latest campaign, but points out that only trade unions, like the PDA Union, can ballot members in relation to taking industrial action, adding that: “This NPA action should therefore not be inaccurately described as a strike or industrial/collective action”. 

According to the PDA – which recently agreed terms for the Boots Pharmacists Association (BPA) to merge into the PDA Union – the action which the NPA is asking members to vote on would more correctly be called “a contractual dispute between businesses that operate community pharmacies and the commissioner, in this case, the NHS in England, Wales and Northern Ireland”.

The union also clarified that “it is those pharmacy owners who are NPA members, and who between them operate around 50% of all community pharmacies in Britain who are involved in this campaign”.

Work to rule in practice

Since the NPA is not a trade union, the results of the member vote will only be advisory, but what could the idea of work-to-rule mean in community pharmacy, and is it a viable tool for change?

Rees says: “If our members were to support taking a form of collective action, it would mean working to minimum aspects of community pharmacy contracts.

This might include suspending free medicine deliveries, reverting to contractual minimum opening hours or halting data collection that is not critical to patient safety. However, it’s important to note members would not be bound to take any action that they did not feel was appropriate for their pharmacy.”

Nonetheless, Alison Jones, director of policy and communications at the PDA, stresses: “This is not industrial action by pharmacists. Industrial action, including working to rule is defined as when employees act against their employer because of a work dispute. This is usually organised by a trade union, such as the PDA.

"The NPA action is a dispute between a provider (a pharmacy business) and the commissioner (the NHS). Our members (employed and locum pharmacists), are not bound to support such an action and employers should also remember that they cannot unilaterally change the working patterns or hours of work of employees to participate in such an action.

"Contracts with employees and locums are entirely separate from the business’s own contract with the NHS and must still be honoured.”

Rees says the call to action “is a last resort and is done with an incredibly heavy heart”, noting that the NPA is still urging the government “to come around the table and provide a significant funding uplift to halt the closures and unleash the tremendous potential of community pharmacy to transform primary care”.

But not everyone agrees that there are no other avenues to be explored.

For its part, the Independent Pharmacies Association (IPA) has spent a busy year bringing what chief executive Leyla Hannbeck calls “the urgency for our contract to be renewed” to the attention of MPs.

One event in September saw a delegation of IPA pharmacy owner members hold a roundtable meeting with MPs from across political parties to address what they explained was a “shortfall in excess of £1.2 billion and rising”. 

“We got unanimous support from the parliamentarians,” says Hannbeck of the event. “They all went away with the action point to ask decision makers to address the fundamental issues regarding the community pharmacy funding without which the sector would struggle to survive. We now need the new government to show that they are listening and invest in community pharmacy.”

What the PDA wants is a seat at the negotiating table. Jones says the union has “consistently offered to become part of the national negotiating bodies to directly support efforts to secure improved funding for the sector”, but that “the existing community pharmacy organisations which are made up of pharmacy owner bodies that negotiate with the NHS, decided that they were best placed to continue those negotiations”.

This position was reiterated at the Pharmacy Show, when PDA chairman Mark Koziol spoke from the floor during a panel discussion to tell Janet Morrison that representatives of employee pharmacists must be given a seat on th negotiator’s committee, because it would be “individual pharmacists who are going to be taking greater risks” as the profession increasingly moves from the supply of medicines to services.

Tensions were further inflamed at the show when representatives from the NPA and the IPA traded accusations over the best way to influence government policy.

IPA board member and former NPA chair Ian Strachan emphasised that fighting for members’ interests should be paramount, even over unity.

He criticised what he suggested were empty threats of collective action, arguing the differing business models of corporates, distance selling pharmacies and independents preclude true co-operation, and called for professionalism, genuine conviction and a focus on policy over politics.

In contrast, NPA chief executive Paul Rees stressed the importance of unity, and criticised the IPA for its isolationist stance, particularly its refusal to join in the handing over of a 350,000-signature petition into Downing Street and a failure to engage with the NPA leadership. 

CPE, meanwhile, has restated its stance that it “regularly reviews its own tactics and approach with regard to what will best support negotiations”, and added that it is “always open to hearing from the sector to inform our approach”.

At such a critical time for community pharmacy the negotiator says it hopes the sector can “unite behind our common cause – to ensure a sustainable and ambitious future to continue to provide essential support patients and communities”. 

As the community pharmacy sector faces one of its most challenging periods in recent history, the outcome of the NPA vote could signal a new chapter. Whether the sector can unite behind a common cause – and whether work to rule can truly bring about change – remains to be seen.