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Are the wrong people making decisions about pharmacy market entry? And are they asking the wrong questions? asks Malcolm Harrison

As the debate over the future of the community pharmacy network continues, too often the discussion is limited to one simple metric – the number of pharmacies open to the public. Is now the time to start to look beyond the front door of pharmacies in England? 

The rate and number of closures is of great concern to everyone within the network and must be taken as a wider indication of the sector’s health. It is however just one way to measure the health and capacity of the network. There is a risk that by only counting pharmacy numbers we assume that what lies behind the front door of each pharmacy is the same, no matter which pharmacy we look at.  

The range of scale across the network, both in physical size, and workload capacity is significant. So called “bricks and mortar” pharmacies can dispense anywhere from 1,000 to 45,000 items each month. Best in class for the New Medicines Service conduct over 1,000 a month, whereas more than 2,000 pharmacies deliver fewer than one per trading day. Significant variance between the volumes of care provided to patients can be seen across all NHS-commissioned services. Behind each metric will be a unique circumstance, but it is clear that the focus on front doors risks missing a much larger and more complex debate. 

If we are to safeguard the future of community pharmacy in England, we must look beyond front doors – both literally and metaphorically. Is it really still optimal to have market entry controlled by a Needs Assessment that is focused predominately on the number of pharmacies per 100,000 heads of population? 

Unfortunately, the way in which market entry is currently controlled can mean that if a pharmacy closes, for whatever reason, there is a good chance that another pharmacy business, whether new or existing, will be successful in applying to open a new contract in the same or similar location.  

Pharmaceutical needs

Pharmaceutical Needs Assessments (PNAs) form part of Health & Wellbeing Boards (HWBs) Joint Strategic Needs Assessment (JSNA) and are used by the NHS when considering market entry applications. The 152 Health and Wellbeing boards were established by the Health and Social Care Act 2012 to act as a forum for key leaders to work together to improve the health and wellbeing of their local population.  

All sounds perfectly reasonable, but the PNAs were first drafted in 2013, before ‘the cuts’ and the ensuing decade of austere pharmacy funding settlements. The nature of public sector budgetary allocation ensures that very few public bodies will ever openly declare they require fewer resources, for fear of losing the associated funding, whilst they also know they are unlikely to receive the additional funding to pay for more. 

The result is a set of assessments that have changed very little in the 12 years since they were first drafted, despite the obvious changes to the size of our population, variations to the demographic split, life expectancy and our ability to treat many conditions.  

Having local government decide on market entry also means local politics can get involved. It is not unheard of for local counsellors to become embroiled in campaigns to grant new pharmacy contracts, or oppose planned consolidations.  

A new approach 

Would the pharmaceutical need for a given population be better assessed by the body responsible for the commissioning of care services in the locality? Following the Health and Care Act 2022, since April 2023, the 42 integrated care boards (ICBs) in England now have devolved responsibility for commissioning pharmaceutical, general ophthalmic, and dental services. The shift of responsibility away from NHS England was intended to enable more joined-up, locally responsive commissioning of these primary care services. In theory it should allow for better integration across care pathways and improved patient outcomes. However, market entry is still controlled by almost 6 HWBs per ICB. Sounds inefficient, doesn’t it?  

The potential conflicts between the interests of ICBs, the HWBs and even local councillors can lead to an erosion of confidence for new community pharmacy providers. In addition, without a commissioner-led and consistent approach, existing providers are less likely to invest to grow capacity. 

And a head count of front doors fails to interrogate the capacity, quality, or resilience of the services provided within. ‘The system’ needs to recognise that access is not the sole determinant of high-quality care. A much more holistic approach is required – one that accounts for the pharmaceutical needs of the local population, and considers the actual and potential capacity of the existing network. 

There’s also a need to balance how national Distance Selling Pharmacies, or online-only pharmacies as the NHS now labels them, can work with bricks and mortar pharmacies to provide care to patients who need it.  

If we are serious about building a resilient and effective community pharmacy network, one that addresses patient need, we must look beyond ‘front doors’. This requires a shift in mindset in how we measure access and perhaps what level of access is required and what the government can afford.  

Without this mindset shift, we risk decisions being made on conflicted priorities, and possibly emotion and politics, over the best interests of patients.  

It’s time to open the conversation, not just the doors.  

Malcolm Harrison is chief executive of the Company Chemists’ Association