NHS England is holding community pharmacy back and the Wright reforms were a missed opportunity, former National Pharmacy Association chair Ian Strachan tells Neil Trainis…

Ol’ Blue Eyes had the lyrics but community pharmacists are enduring the reality. As a government that has long been unwilling to properly support pharmacy teams across England continues to get under their skin, an interview with Frank Sinatra seems fitting. Well, Sinatra’s tribute act anyway.

Ian Strachan is known in pharmacy circles for quite a few things. He was the National Pharmacy Association chair between 2014 and 2018 and a board member until he resigned in October over concerns about the organisation’s direction of travel – “governance was a big part of it,” he says, suggesting “its management, its board, seemed to be distant from its membership.”

He’s a qualified pilot and has graced weddings, restaurants and hotels with his Sinatra tribute act, belting out classics such as Fly Me to the Moon and Come Fly with Me.

One local newspaper gave him the moniker the Crooning Chemist. Ian does a very good Sinatra. He bears a passing resemblance to him and the star’s influence on Ian manifests itself in other ways too. For instance, he set up a pharmaceutical wholesaler last year and called it Reprise Pharmaceuticals Ltd after Sinatra’s 1960s record label.

“I’ve not done anything with Reprise Pharmaceuticals yet. But you’ll be the first to know when I do,” Ian says, smiling as we chat on Teams. “I have a reputation for singing Frank Sinatra songs. He settled for a label called Reprise in the 60s. He took a load of standards from the 50s, he did a capital, and then he relabelled them as Reprise and basically started to sing the same songs but with different arrangers and brought them out better.

“Mavbe it’s my rendition of some songs… maybe I’m going to become an artiste and sing my way to the top.”

The other thing about Ian is he’s not afraid to speak his mind or ruffle feathers when they need ruffling. And when the conversation turns to community pharmacy’s prospects, he makes it clear he’s not impressed with NHS England who he believes is holding the sector back.

NHS England are ‘the impeders, the blockers’

“What you’ve got to do is distinguish between the government of the day, we don’t need to be partisan about it, and the machinery of government. The machinery of government is who delivers on its strategies. That’s NHS England, Department of Health. I think you’ve got to make that distinction because I’ve never come across a politician yet who hasn’t got pharmacy, who hasn’t seen the merits of it, who hasn’t seen the value of it, who hasn’t seen the potential of it, who hasn’t been prepared to embrace it.

“That applies to cabinet ministers, to prime ministers, to backbenchers. I don’t think the problem really lies with politicians. Politicians are not stupid, they know we’re a loved sector that’s respected, admired, trusted, and they know that equates to votes if you look after them. There’s a huge difference between the machinery of government and the politicians and that’s where the barriers are.”

He insists those barriers are being driven not by the politics but by “hard-line policy” and describes NHSE as “the impeders” and “the blockers.”

“I was told back in 2015, I think it was, that there’s two fundamental problems with pharmacy with commissioners. One, they all think we’re all swimming in cash. Secondly, they think you’re a gang of clinical misfits, failures, who are not up to speed with your clinical pharmacists as they were called then or your pharmacists in PCNs or pharmacists in doctors surgeries. That’s where, inherently, the problems lie. It comes down to trust.”

In Ian’s eyes, the Covid pandemic was a setback for NHSE because it exposed how fundamental community pharmacy is to the NHS. Or to put it another way, how helpless the NHS is without community pharmacy. And that, he suggests, did not fit their narrative.

“NHS England are the ones who are trying to manage an awful lot of recognition and goodwill that’s landed our way since the pandemic. I mean, it was the best PR campaign we could’ve had and they’ve had to manage that because it does not sit in the sights of where they want the scope of this sector to lie.”

Whenever criticism is levelled at NHS England, however, one thing that crosses the mind is the chief pharmaceutical officer. Keith Ridge was often accused of not having community pharmacy’s best interests at heart and his successor David Webb has had little to do with the sector having spent much of his career in hospital pharmacy. Ian insists “it’s not about personalities, it’s about cultures.”

“What you’ve got to understand is to get multidisciplinary working across Trusts, secondary care, primary care, across individual practitioners within a discipline is difficult. It’s challenging. The challenges are because of cultural differences, they’re because of the leadership that drives those cultures and that is what you’re dealing with here.

“You’re dealing with a lack of trust in community pharmacy, a recognition or an appetite to even embrace it. And they’re some of the real challenges we’re facing right now.” Ian says the problem as far as community pharmacy is concerned lies far beyond any chief pharmaceutical officer.

“This lies at a much higher level. This lies at a strategic level, where commissioners are making big decisions for tax payers and how to deliver the best outcomes for patients. I could explain to you for 20 minutes how pharmacy ticks all those boxes by the way. But that is what you’re up against.

“I described it as a prejudice back then when I look back on it years ago. I would still describe it as that, that no matter what logic you put in front of people, what evidence or whatever you do to substantiate the fact that we’re right, I just think we are against a group of people who really don’t believe in this sector as a solution to the majority of challenges facing the NHS.”

Grim picture of pharmacy in the north

The impact of poor funding is there for all to see. The community pharmacy network is beginning to crumble. When the second largest pharmacy chain in the UK embarks on a nationwide fire sale of branches, you know things are bad.

And if the multiples are struggling, how are the independents managing to survive? Ian says the two pharmacies he owns in the North-West have suffered but insists he hasn’t had to scale back their services or reduce their opening hours. Doing so, he says, would be “self-defeating.”

“You’ve got to stay open for those hours. That’s the hours of supply. We rely on supply. Our business model is predicated around supply. You’ve got to stay open, that isn’t really an option. You can do things that are on the fringes. You can charge for deliveries, you can charge for MDS, you can scrutinise who you take on for these things, you can really evaluate your cost base and we do those things but essentially, that’s where you haven’t got room for option.

“I guess where I have been fortunate in one respect is I didn’t borrow for my pharmacies, so I didn’t acquire them through acquisitions. I basically set them up from scratch which helped.”

He’s looked at his cost base but says it’s now “practically impossible” to strive towards “a surplus.” He paints a grimly realistic picture of community pharmacy, particularly in the north of England.

“For me, the more you rely on the NHS, the harder it gets, particularly in areas like the north. You are heavily reliant, particularly in the kinds of communities where my pharmacies are which is surrounded by lots of chimney pots. You’re surrounded by a demographic that relies maybe to 96 per cent on NHS. I think these are the ones which find it most difficult.

“That’s why it was 620 pharmacies or whatever it was that closed recently and something like 40 per cent of those closures were in the 20 per cent of the most deprived. There’s reasons for that. When you’re reliant upon that, then you’re going to hit cashflow problems pretty quickly. And cashflow comes down to how deep your pockets are and what you can pull in on and what assets you’ve got.

“For the majority of pharmacists, they can only ask for deferments, they can only ask for staggered repayments, they can only factor once, they can only increase their overdrafts maybe once or twice. But there comes a point when you’re constantly chasing a spiral of debt, 30-day debt, that just gets basically harder and harder and that’s the reality of closures I’m afraid.”

These are desperate times. Nurses, train drivers, teachers have gone on strike recently but community pharmacies struggling with cashflow problems cannot afford to. To strike would be to make a bold statement but risk worsening their plight. But when your back is against the wall, there’s usually a way out of trouble. For community pharmacy, that might be the next general election.

Labour politicians, notably the former shadow health secretary Jonathan Ashworth, have lavished the sector with platitudes down the years. They have promised to reverse the funding cuts and support pharmacies. Ian is sceptical.

“There’s an old saying in the north; talk’s cheap, money buys houses. When you’re shadow front bench, it’s very easy to make these claims, it’s very easy to say what you will do. Like I said to you before, you’re hitting a very rigid, strategic position adopted for many years and you’ve seen it in the language of the CEO of NHS England (Amanda Pritchard) and previous CEOs of NHS England.

“You can tell they’re up against a very rigid belief here. If we are going to overcome that, it will require a steel from any opposition and it’s going to require a conviction, a real belief in community pharmacy and to drive that through. If I’m being honest, I wouldn’t just take words on this basis. I think you’ve got to actually see it happen. I hope it does, I really do, because we’re a huge solution.”

Evidence to the APPG

Community pharmacy has arguably fared better under Labour than the Conservatives historically but a chink of light crept through the cracks when the health and social care committee chair Steve Brine promised to hold an inquiry into community pharmacy this year.

And pressure is being exerted on the government. An All Party Pharmacy Group report published in January said community pharmacy’s clinical value has been underestimated and, as a result, the sector has long been treated separately from the wider NHS “machine.” It insisted the clinical value of pharmacy teams remains under-utilised, under-resourced and, in some cases, wasted. Ian, who gave evidence to the APPG, is asked if he thinks it boils down to general practice ultimately lacking respect for community pharmacy’s clinical abilities.

“It's improved from the 80s and the 90s when I started. But yes, it still exists. If you look at recent evidence and some of the exchanges around evaluating the health bill that became statute in 2022, the integrated care systems.

“One of the features of that is that multidisciplinary working wherever it sits is a challenge, partly because of funding and the way the funding streams work and reconciling national and local government because it’s a big problem.

“It's a much bigger problem than you realise. From a cultural point of view, there are blocks, there are barriers to community pharmacy and very much that leadership that drives those cultures is a problem. And that has to come from the top. For me, we’re never going to get integration of pharmacy until we’ve got trust because integration can only go at the speed of trust.

“I said this to that APPG inquiry. You’re locked into a culture where there’s got to be that willingness and I guess the evidence of that will be highlighted once we get our teeth into integrated care systems and where that goes.”

Integration, collaboration and community-based healthcare are watchwords underpinning the government’s vision for an NHS that’s fit for the 2020s and beyond but the Tories are a muddled contradiction. They want to take care out of hospitals and into local communities but refuse to back community pharmacy. One NHS overhaul has been followed by another and each one has given the sector little reason to believe it has an important part to play. Community pharmacists didn’t exactly thrive or enjoy significant involvement in healthcare decision-making during the era of clinical commissioning groups under the Lansley reforms and it doesn’t seem things will get much better with integrated care systems and boards. General practice, after all, sits at the centre of the healthcare universe.

“Yeah, that’s true but the idea of integrated care was about having this collective responsibility across different providers, NHS, local authorities, other people,” Ian says. “Its remit was to include health outcomes, reduce inequalities in society, statute these ICBs which were hard-wired to local government and the public health trusts and social care trusts and then you add the ICPs (integrated care partnerships) where you have local authorities and voluntary care groups.

“Sadly, for the integrated care system, it landed in about the middle of the mother of all storms where we had political instability, three prime ministers, economic instability, we’ve had strikes, we’ve had inflation, we’ve had inadequate regard for reducing inequalities and that was because of the cost-of-living crisis, all of these things hit at the same time. It's been a real challenge and they’re really trying to address the next five minutes at the moment, not the next five years.”

Pharmacy hindered by ‘cultural barriers’

Ian says integrated care will only work if health providers are brought close to people’s homes, something that comes naturally to community pharmacy. “If you’re trying to stop smoking, trying to stop drinking, trying to lose weight, then you’ve got this mentor which is within five minutes’ walk from your doorstep where you can access them without an appointment more often. That’s why we were so good at smoking cessation. I think we were one of the best primary care providers in that domain because of the behavioural support we could give people.

“Another remit in the Long-Term Plan was to improve efficiencies and productivity in the NHS. Well, there you go again. There are countless examples of where pharmacy is strong there.”

Positivity though, is undermined by those “cultural barriers,” the biggest of which he says is “this idea of national and local government because they cannot be competing priorities.”

“ICSs, up to now, have been this coalition of the willing on these integrated care boards but you can’t be a coalition of the willing once you get into the realms of statutory law and that’s where we are now.

“They’ve got a legal obligation on the ICBs and on the ICPs, they cannot be ignored. National has got to start to recognise that they’ve got to work with these ICBs and they can’t have conflicting agendas. Those are the kinds of soundbites coming through right now, that some of these ICBs are getting frustrated by the fact that they’ve not been able to land the commissioning or listen to the ICPs enough because they’re the ones developing strategies for these things.

“Subsidiarity is not a word that’s best in favour…and that’s all about devolving responsibility to others. You can improve the best outcomes by devolving that power down to providers, then downloading that power down to neighbourhoods and places. We’re not in that space yet but that’s where we’ve got to deal with integrated care.”

Ian says the problem is more than red tape and bureaucratic management. “It’s ignorance, naivety. There is still a lot of centralised influence. The 41 ICSs that we’ve got have all got CEOs. Some will get it, some won’t. They’ve come from a system of recruitment and management and heritage that probably isn’t all that familiar with pharmacy and I don’t think it’s getting the best mentoring from the top as well.”

Community pharmacy’s fate is largely out of its own hands but it has had to take a long, hard look at itself too. Shortly after contractors voted in favour of proposals to reform PSNC and LPCs, Ian took to Twitter to question whether it was “a missed opportunity squandered by ignorance, fear and self-interest.”

Asked to elaborate, he says the reforms missed the “opportunity in pharmacy for us to understand the kind of people we democratically elect, what they stand for, what their purpose is.”

“I thought the Wright review, if it had been embraced in the right way, would’ve been uncomfortable for people because it would’ve exposed poor performance,” he says.

“It would’ve exposed whether people really did act the way they articulate on social media or what they say, it would’ve provided an opportunity for people who vote for people to see what they really stand for.”

He believes the NPA should not have advised its members to vote yes to the reforms. “It was an example of a decision where I didn’t think it was right that we went with ‘yes.’ I would’ve gone with ‘no’ and told the board that.”

Ian would have done it his way, you might say.