By Ade Williams

Mathematician Benoit Mandelbrot’s geometry-centred research has contributed to fields including financial modelling, medicine, economics, social science, chaos theory and the “butterfly effect”.

Mandelbrot characterised the patterns he saw in the historical data of the world’s great rivers by borrowing stories from Genesis. ‘The Joseph effect’ describes persistence: trends tend to persist. Declining health outcomes over five years are likely to continue. The ‘Noah effect’ describes discontinuity: when something changes, it can change abruptly. The value of an out of patent medicine has a cliff edge: it will go from £75 to £5. 

Although the ‘Noah’ and ‘Joseph’ effects push in different directions, you can summarise them together as things will carry on as they are until a disruptive change arrives, when all the old rules are broken. I continue to see instances of these effects play out in my community pharmacy life.

Take the new contract. I remain sanguine in my analysis so far. Like most contractors, I recognise that five years offers some degree of certainty, but my sustainability concerns persist. Seeking to align our sector with the broader NHS Long Term Plan is to be welcomed, even with piloting first. However, sustainability by squaring the increasing cost of running a business, while delivering services, with no provision for inflation or unforeseen disruptions like a no-deal economic storm, will be difficult. 

One particular change has me most worried – the loss of MURs. The service has been panned for years. Evidence of value for money or research supporting clinical outcomes are conspicuous by their absence. The allegations of ‘gaming’, with reports of financial targets and the subversion of clinical and professional discretion through questionable recruitment of patients  MURs were a service with many headaches, made worse by lobby groups like the Taxpayers Alliance putting our dirty linen into the public domain.

Of course, we should have built a better model to demonstrate value and proposed changes to maximise patient benefits

Before MURs most patients did not use or even know of their pharmacy’s consultation room. Most pharmacies did not use them either, or if they did it was for extra storage space. It took a while for many to get comfortable talking to their patients in a clinical context, not because we did not know how – the ‘art’ of being discreet over the pharmacy counter, steering a conversation to build a picture, while not causing embarrassment, was a unique pharmacy skill.

What are we losing with the loss of MUR in community pharmacy, over and above the remuneration which since the funding cuts has become more valuable than ever? I’d say the ability to offer structured conversations to a wide range of patients, ensuring safe and appropriate medicine use. Medicines optimisation is a key part of the NHS England agenda, and community pharmacy is needed to deliver it. I know we can still achieve this without this particular remuneration but, as in general practice, the contract shapes service delivery more than aspiration does.

Of course, we should have built a better model to demonstrate value and proposed changes to maximise patient benefits. But I hope any retrospective analysis of the impact of stopping the service will not show any hindrance of the NHS Long Term Plan goals because, in my opinion, this was also a gateway service for long-term care ownership. It defined our profession’s relationship with patients, and their perception of us as clinicians. And our broad access made it a natural act to intervene, and not just one that was needful or mandated. 

At our best, we in community pharmacy use our goodwill to influence and support change in behaviour and lifestyle. But creating financial models for this has always been our challenge. Now though, I expect to see the ‘Noah’ effect play out. The culture change in the community pharmacy practice model will not be intentional, but it will happen.  

Picture this. In 2026, a new national community pharmacy mental health consultation service is announced. Our increasingly digitally-enabled society has seen physical health outcomes improve significantly, but mental health remains at a crisis point. 

I’d hoped for a shorter timescale. Last year, I can tell you from my practice audit records, I provided 157 brief mental health interventions and referrals. While the visits from senior colleagues and politicians to see the incredible potential of these interactions – through consented sit-in sessions – were all very well, it would have been more valuable to collate data much earlier to build a proper case. 

Sadly, I think this last point remains our contract negotiation’s Achilles’ heel.