By Rob Darracott

Since the publication of the Independent Review of Community Pharmacy Contractor Representation and Support (the “Wright Review”), much of the focus for community pharmacy’s national organisations in England has been on the shape (and cost) of future representation. That’s unfortunate for two reasons. 

Firstly, discussions about who makes the decisions and how many chairs are around the table can prove time-consuming and are never easy – believe me, I’ve been there. Throw in suggestions for limiting the time individuals can sit at the top table and it is no surprise it will be getting on for a year since David Wright and his colleagues unveiled their report before we get a clear sense of what might be  coming next. 

More importantly, the focus on structures – including of the negotiating machinery itself – means less attention has been paid so far to three recommendations to plug gaps in pharmacy’s support mechanisms with considerable potential for impact. 

Recommendations 10, 11 and 14 of the Review cover the need for a national vision and strategy; communications to enhance the external perception of the sector, and an inclusive approach to policy development in support of the national negotiations. 

In other words, the sector needs a clear sense of what it wants the future to look like and how it intends to get there. It needs formal policy processes to work up the detail, and a communications strategy to sell that to the public and those who commission it. I'd say it also needs an approach that involves contractors and pharmacists on the front line. It’s their future too, and it is probably no coincidence that there are increasing reports of a brain drain into general practice, which offers real development potential and scope to use the kind of skills now being extensively acquired in schools of pharmacy.  

The development of a new vision for community pharmacy might not need a completely blank sheet of paper

Ordinarily, given that pharmacy services evolve over time, and particularly with a five-year contract agreement in place, this might not matter much. However, as we have reported several times in the past

year, the pandemic crisis has prompted considerable change within the health system, including a speeding up of decision making, particularly at a local level. Now, with organisations like the NHS Confederation talking about a post-pandemic “reset”, which keeps the best of what has been learned, and the confirmation by NHS England of a further 11 integrated care systems, making a total of 29 covering 60 per cent of the population, community pharmacy may need to be involved in discussions on a number of fronts or risk being left outside the tent again.

Professor Wright was clear about the benefits of having a national vision and strategy, saying it would lead to a “better understanding of the issues faced by community pharmacies, better understanding of community pharmacy plans externally [ie by NHS England, other healthcare professionals and patients], improve focus with respect to local and national activities, and strengthen and underpin the national negotiating strategy”. He pointed to Community Pharmacy Scotland’s strategy, which was developed alongside and is significantly aligned with NHS Scotland’s, as beneficial in simplifying the negotiating process. 

He also notes that the last national vision for community pharmacy – the Community Pharmacy Forward View (CPFV), which was developed in 2016 by the now defunct Pharmacy Voice (PV) and the Pharmaceutical Services Negotiating Committee (PSNC) with support from the Royal Pharmaceutical Society – “is no longer in the national consciousness”. 

That’s true, although you will find references to it in the pharmacy press from time to time. However, a rereading of it today, with a reminder of aspects of its back story, suggest that the development of a new vision for community pharmacy might not need a completely blank sheet of paper.

The CPFV was originally intended by PV as a pharmacy response to the NHS’s Five Year Forward View, published in 2014. When the funding cuts were announced in the December 2015 Community Pharmacy in 2016/17 and Beyond letter, the strategy development process was broadened to include other organisations and  repurposed as a formal response to the consultation on the Government’s plans that followed. The outcome was submitted to the Department of Health and Social Care (DHSC) at the end of May 2016. 

The CPFV envisaged a future for community pharmacy focused on three domains: 

• The facilitator of personalised care for people with long-term conditions
• The trusted, convenient first port of call for episodic healthcare advice and treatment 
• The neighbourhood health and wellbeing hub.

Looked at almost five years later, some elements of that future stand up to scrutiny better than others. On developments in long-term conditions management, the CPFV is bang on the money in addressing the need for more ‘right care’. However, much of the investment in putting pharmacists into general practice is designed to deliver the kind of services community pharmacy organisations wanted to see in community pharmacies in England in 2016. 

Was it a pipe dream in England? The staged development of the Medicines Care Review (MCR) service in Scotland – previously the Chronic Medication Service (CMS) – suggests not. The service is still evolving, and it incorporates aspects of care similar to England’s New Medicine Service and the mediciens safety audits within the Pharmacy Quality Scheme (PQS). But some elements are still in play, though delayed by the pandemic – notably, support for safe discharge from secondary care is coming soon (and is working in Wales), and medicines reconciliation. The CPFV also include routinising medicines optimisation using independent prescribing skills allied to electronic repeat dispensing (eRD) in its wishlist. With eRD now expanded (at last) as a time saver during the pandemic, this option remains too. 

Looked at almost five years later, some elements of that future stand up to scrutiny better than others

This section of the CPFV also had a lot to say about local partnership working, including that “pharmacists should be operating as part of ‘integrated primary care networks’ [they were announced in 2019’s Long Term Plan], both to facilitate effective referral of patients around the system, and to build confidence in community pharmacy teams’ ability to take on these new roles”. It highlighted the need for registration of some patients (also a feature of Scotland’s MCR) and for community pharmacies to work together locally – another feature of today’s PCNs (see panel, below).

Job done? Not quite; the ambition from 2016 was that a ‘pharmacy first’ attitude would be ingrained in patient, public and professional behaviours, with access to these services “via a variety of routes, including online”. As we reported back in July (link here), tech companies who have been pushed to deliver digital developments at pace for general practices during the pandemic response say community pharmacy had been largely absent from those discussions. There’s work to be done there, too. 

Lastly, in the section on acting as a neighbourhood health and wellbeing hub, the CPFV envisaged community pharmacies ramping up their local outreach activities in their communities and to employing organisations. We have seen during the past year many community pharmacies recognised by politicians and community leaders alike as the local community resource and social asset they are. We have also seen, in particular through the PRINCIPLE trial featured on page 18 of this issue, the fulfilment of a wish for community pharmacy teams to “participate in collaborative research”. 

At the very least then, the CPFV could prove useful as a starting point or baseline for the development of a new vision and strategy for community pharmacy in England. And, in 2021, that vision would be enhanced with new examples of what the 2016 document says “is already happening across all or part of the community pharmacy network”, supplemented with pharmacy’s own Covid experiences too.  

There are, however, key enablers for future development that need some work. Without resolution, or options, these key issues stand in the way of thinking differently about what community pharmacies could deliver for patients and the public. In Wright Review terms, they are the sort of issues that might be considered by the policy development groups in recommendation 14, particularly if constituted so as to “bring in appropriate external expertise to provide additional and different perspectives to discussions”. 

More thoughts on three of these key enablers – workforce and skills development, the use of automation and representation and the local agenda – can be found in the separate panels in this article. 

Of course, it will be up to Community Pharmacy England – if the renaming recommendation of the Wright Review is adopted – to determine whether a clear vision, and a strategy to achieve it, would be useful at this stage. But as other parts of the UK seem to have found a strategic direction agreed between community pharmacy and NHS/government to be helpful, it might even prompt a genuine partnership approach to the direction of travel. At the very least, contractors might have a better sense of where they were headed.