Capacity and workforce are not covered in any contract framework but they could be the next problems the sector has to face up to, says Patrick Grice…
It’s a great result. Over 10,000 contractors in England have now signed up for the community pharmacy consultation service (CPCS).
They may have been driven to do so out of financial necessity, given no choice by their head office, or simply wanted to broaden the scope of their practice away from the dispensing bench. Whatever the motivation, it sends a strong message to our paymasters and provides a solid platform from which to take the new service forward.
The PSNC must be delighted. Too early yet, though, for contractors to take a bow. The next bit – reacting to those referrals from NHS 111 and delivering those consultations effectively – that is where the jury will focus in the months ahead when determining how well CPCS is delivering.
There will be other hurdles to cross as the new deal for pharmacy contractors in England unfolds This is, after all, a five-year plan. However, there is one thing that is essential for the delivery of any service, and it is not covered in the contract document. It is, however, something PSNC chief executive Simon Dukes says keeps him awake at night.
That ‘something’ can be summed up in one word – capacity. Community pharmacies can only deliver the new contract if they have the capacity within their businesses to do so, and that applies equally to Scotland, Wales and Northern Ireland.
Capacity can simply be defined as what a company can produce or deliver using its current equipment, workers, capital and other resources at full tilt. In simple terms, it is the financial limit of a business or person. It is also worth noting that no business can operate at full capacity for a prolonged period: equipment fails and people get worn out.
There is a widespread belief that capacity in community pharmacy’s volume-driven dispensing business can be increased by more automation and hub-and-spoke dispensing. This might be the case for the likes of Pharmacy2U and the larger multiples that can make hub-and-spoke work for them but the evidence is thinner for independents - and this is without taking into account the legal position which currently makes hub-and-spoke a non-starter.
Independents are more dependent on leveraging industry-wide changes. The efficiencies that computerisation, barcoding and scanning and original packs have brought over the past two decades cannot be understated.
These innovations have revolutionised stock ordering and handling and streamlined the dispensing pathway. They have helped make dispensing robots a viable proposition for independent pharmacies with above average monthly prescription figures.
For items where customer intervention is not required, prescription collection robots can automate even this stage of the process. Their proponents suggest you can automate 60 per cent of the workload associated with the handing-out process, cut errors and partly replace a pharmacy’s delivery service.
All these things help cut patient waiting times, reduce dispensing errors, improve stock management and free up capacity. But now there is a strong argument that to improve efficiencies further in the dispensary, it would be better to focus on pulling together health networks and getting the integration right between different settings.
An example of this is the pilot being overseen by NHS Digital in Leeds where information about flu vaccinations is being sent from pharmacies to GP practices. Only pharmacies using PharmOutcomes and GP practices using SystmOne are able to send and receive the electronic notifications at present, but the benefits are obvious.
As well as saving time for pharmacies and GP practices, there will be improvements in data quality and the reduction of errors by, for example, making sure patients who have already had a flu vaccine are not contacted unnecessarily to arrange an appointment.
But another element of capacity is human resource and here the alarm bells are really starting to ring. Community Pharmacy Northern Ireland has highlighted the shortage of community pharmacists there, caused by the perfect storm of funding issues, an exodus to GP-practice posts and declining student numbers.
CCA chief executive Malcolm Harrison warned last month that community pharmacy was facing the same recruitment and retention crisis as general practice, citing fewer students choosing to study pharmacy and “an osmotic draw” of pharmacists into primary care-based roles.
The number of applicants to schools of pharmacy has dropped and all schools went through clearing this year to fill their places, he said. A recent analysis found that 21,104 students applied to study for an MPharm degree in 2016/2017 - the lowest figure in the previous seven years and a 14 per cent drop over that period.
The drift of pharmacists into GP practice roles has not become a stampede because in many cases, the salary differential has made such a move unattractive. But don’t be persuaded that community pharmacy is seen as a better career option - morale is not good, especially if you work for a multiple. It’s the money that’s talking.
Taking a step back, there does seem to be a lack of joined-up thinking between the Department of Health and Social Care (DHSC) and NHS England and, one suspects, a shift in the balance of power as regards community pharmacy between the two.
The DHSC has championed the massive shift of pharmacists into GP practices. From pretty well zero, there were 1,029 FTE clinical pharmacists working in general practice at the end of March 2019. NHS England, meanwhile, has championed the integration of community pharmacy services into primary care as epitomised by the CPCS.
An NHS briefing document published in June said “the numbers of clinical pharmacists will be expanded and, by 2023/24, a typical PCN of 50,000 patients could choose to have its own team of approximately six whole-time equivalent (WTE) clinical pharmacists.”
Quite where all these pharmacists will come from is a mystery. Workforce issues seem to have been left out of the masterplan and unfortunately there is no quick fix. Measures to boost the numbers in the pipeline now will not bear fruit for at least five years.
In this context plans by a group of employers to develop an apprenticeship route to qualification seems like a prudent move in as much as it ties the student pharmacist to an employer for a lengthy period.
These people have seen what’s coming and are doing something about it (as well as getting some payback from the apprenticeship levy they have been paying).
Of course, it may be that script numbers, which are currently plateauing, will fall dramatically with de-prescribing and pharmacy numbers will fall significantly, unable to survive five years of flat funding. But there isn’t much sign of either of these things happening at the moment!
On that note, best wishes for a happy Christmas. You might be given something wonderful by Santa, like a magic hat - a Capacity Cap - which enables the wearer to do infinitely more with ever fewer resources.
Or a recruitment stick - whack the dispensing bench once for a pre-reg student and twice for a pharmacist. But then maybe you won’t. Whatever, here’s hoping you have a prosperous 2020.
Patrick is the contributing editor for Independent Community Pharmacist.