Agenda item

Attending for this Item were:

NHS England (NHSE) – Midlands Region

Terry Chikurunhe, Senior Commissioning Manager

Satyan Kotecha, Local Professional Network Chair for Pharmacy

Worcestershire County Council Public Health

Matthew Fung, Public Health Consultant

Cllr Karen May, Cabinet Member with Responsibility for Public Health and Well being

The Committee were provided with an introduction to the Report, the main points included:

·       Community Pharmacies (often referred to as ‘high street’ pharmacies) were an important part of everyday life and an integral part of the NHS, especially as they were often more accessible compared to other health professionals. During the COVID-19 pandemic, pharmacies had performed well and services had been maintained

·       The role of pharmacies was moving from only dispensing prescriptions to providing consultations, vaccinations, additional clinical services and supporting general practice and urgent care settings. In addition, the commissioning of community pharmacies was transferring from NHSE to local Integrated Care Boards from 1 July 2023

·       Worcestershire had 95 Community Pharmacies. The latest Worcestershire Pharmaceutical Needs Assessment (PNA) was published in October 2022 and provided detail on current provision and future proposals

·       Examples of other services which community pharmacies could offer included consultations, stop smoking services and flu vaccinations. Across Herefordshire and Worcestershire, 21 pharmacies also delivered COVID-19 vaccinations, either at the pharmacy or off site

·       Some Community Pharmacies were taking part in pilot schemes, such as oral contraception management and the supply of medicines used in palliative care

·       The Herefordshire and Worcestershire Integrated Care Board (HWICB) vision was that community pharmacy was central to primary care and during 2023 was proposing to work more closely with General Practice to improve overall patient experience

·       The main challenge for pharmacies was workforce, especially as the demand for services was increasing. Nationally, a large pharmacy chain was closing stores, further increasing demand on existing provision

·       Some pharmacy buildings may not always be suitable to offer additional services, for example not having the physical space to offer private consultations or vaccinations

·       A further challenge was sometimes sourcing medication, however, there were processes in place if there was a national serious shortage.

Members were invited to ask questions and in the ensuing discussion, the following points were made:

·       The Local Professional Network Chair for Pharmacy highlighted that community pharmacies were contracted to deliver a service, yet many went above and beyond the contract to improve the health of the patient.  In addition, it was believed that staff skills should be fully utilised and there was lots of opportunity to integrate services

·       Current NHSE commissioning teams would transfer to ICBs ensuring knowledge is maintained, however, some finer detail was not yet finalised

·       In relation to medicine shortages, Members learned that at any point, there was a 6 week supply of medicines in the pharmacy system and NHSE encouraged a 28 day interval in prescriptions. Historically, the UK was the cheapest place to buy medicines, however some manufacturers had closed their UK supply, perhaps due to the UK leaving the European Union or other factors

·       Examples of recent shortages included penicillin and hormone replacement therapy (HRT) and it was not uncommon for a Pharmacist to spend 2 hours a day trying to procure stock. If there was a concern, the Pharmacist would speak with the GP to arrange an appropriate alternative medicine 

·       For clarity, a Pharmacist cannot control what is on a prescription and patients with queries, would need to contact the GP. Patients were able to ask the pharmacy team to check where their prescription was on the electronic tracker and the NHS app would also indicate whether a prescription had been written or sent to the pharmacy

·       Practical examples were given when medicines were in short supply, such as part filling an order to ensure stock was available for the next patient or the pharmacist speaking with the GP to prescribe an alternative. This however was fraught as pharmacists did not have direct access to a GP and would telephone the publicly available number

·       A Member asked whether the growth of independent prescribers would result in a 2 tier system, to be informed that by 2026 a further qualification would be required. Health Education England was currently working with universities; however, it was a challenging target. There would always be the requirement for a Designated Prescribing Practitioner (DPP) and mentoring roles

·       Legislation was expected to allow those pharmacies which were contracted to open for 100 hours each week to reduce their hours if there was staffing concerns, however, there was no desire to reduce all pharmacies to 40 hour a week contracts as accessibility would then be of great concern

·       In relation to Out of Hours provision, it was suggested that there were very few medicines which needed to be taken immediately, however, if there was an absolute need, the HWICB would commission such a service. At present, it was known that a County resource was available until midnight

·       A Pharmacist would study a 4 year degree and complete a 1 year pre-registration training period before passing a further examination. Pharmacy staff could also include dispensers and technicians. Pharmacy staff are paid at nationally set rates and it was reported that the current cost of living crisis was challenging, with some staff having left the profession to join other sectors due to improved pay

·       It was hoped that HWICB would look at workforce across the whole pharmacy portfolio and provide integration and career opportunities across all sectors

·       The Self Care Agenda had been in place for 5 years, resulting for example with people presenting with an insect bite being advised to purchase a product. If the bite had been infected, a Pharmacist would know the antibiotic required, but was not authorised to prescribe. A pilot project was underway to reverse this and it was hoped that the most common GP visits which could have been avoided as there was a clear pathway of treatment could release GP time. It was noted that confidence was building in community pharmacists and it was hoped that the pilot projects could be built upon

·       When asked whether the delivery of enhanced services attracted more funding, it was reported that payment was above the contract. However, there was no incentive to give antibiotics

·       A Member suggested that pharmacists generally had a better relationship with patients than GPs but asked whether community pharmacists were viable. In response, it was reported that in a recent survey 92% of 6,000 pharmacists surveyed said they were struggling and had concerns about ongoing viability. It was agreed to circulate to the HOSC a recent pharmaceutical briefing on funding pressures

·       The prescription charge was currently £9.65 per item and patients had been known to decline an item or only choose certain medication due to financial pressures. Staff would be able to advise whether a prepayment certificate, which was a set fee for a 3 or 12 month period, was an option however the full fee was applicable on application. Furthermore, patients prescribed HRT could also explore a specific prepayment certificate. An alternative would be for the patient to ask for the prescription quantity to be increased, for example by asking their GP to increase from 28 days supply to 56 or 84 days supply

·       It was clarified that although a prescription was £9.65 per item, and some medicines were highly subsidised, the Pharmacy would not receive any of the money, rather it would receive £1.05 for dispensing each item. Members heard that the system was disjointed and any improvement would be welcomed

·       When asked whether premises were checked as being suitable, including for example being dementia friendly, it was clarified that the General Pharmaceutical Council (GPhC) and NHSE required premises to be fit for purpose as part of contracting arrangements. Furthermore, a self-assessment had to be completed annually and visits could occur every 3 years or if a complaint had been received

·       When asked whether the pharmacy sector was downsizing, the HOSC was advised that although very challenging the sector was resilient and would overcome recent developments seeing nationwide closures. The PNA would also identify any gaps and make recommendations. The industry also hoped that integration would build better relationships and that a multi-disciplinary team approach would develop

·       A Member referred specifically to Bewdley, where neither of the 2 pharmacies opened on Sundays or Bank Holidays. It was suggested that core funding would cover 40 hours, however, individual pharmacies could provide supplementary hours if they wished. The PNA had not identified any gaps in provision for Worcestershire, however, if there was a concern, then further opportunities could be explored

·       The Chairman read a question from a Member who could not attend the meeting. There was concern about the need for patients to collect controlled and temperature sensitive drugs from a particular GP surgery, yet residents were mainly elderly, had disabilities or often had no transport. It was suggested that the case referred to a dispensing GP surgery and there was nothing in the contractual framework about delivery as it was not contractual nor an essential service. Members noted that a dispensing GP would receive more than £1.05 per item to dispense

·       In relation to location, ideally a pharmacy would be available to everyone within in a 10-20 walk, however, patients were able to choose what service worked best for them. It was known that if a delivery service was an important factor, then patients were locating a pharmacy that offered that service. Likewise, if medicine shortages was commonplace for a patient, they were likely to move their business to an alternative pharmacy

·       A Member asked whether financial clawback existed, to be informed that it was, but not in the current year

·       HWICB would have a Chief Pharmacist and each Limited Company would have a Responsible Pharmacist. Within the industry there was concern that if rules on the Responsible Pharmacist were to be relaxed, how could patient safety be ensured

·       There was a duty on Health and Wellbeing Boards to produce a PNA every 3 years and Worcestershire’s was published in October 2022. Its recommendations included accessibility to information, for example individual pharmacy opening hours and services offered. It was noted that a listing was available on the website, however, there was no search function, such as if a patient was seeking a particular service. A gap had also been identified whereby pharmacists did not have access to translation services in the same way as other health professionals. It was acknowledged that the landscape was changing and it was hoped the transition to ICBs would encourage more integration and signposting to other services.

The Managing Director of Healthwatch Worcestershire was invited to comment on the discussion and made the following points:

·       Following the introduction of the self-care agenda, patients had got in touch to say that they could not understand why items such as paracetamol or hay fever medication was no longer being prescribed

·       Availability of workforce and availability of medicines was of concern to patients and communities

·       Commissioners should be mindful of service quality and ask whether pharmacists had the capacity to do anything other than dispense. Furthermore, when GPs were under pressure, why were pharmacies not conducting all vaccinations for example?

In response it was stated that if pharmacists were planned to complement GP services then additional funding must follow. There was a need to think about the patient and further develop a patient centred approach to care. A positive example was the recent introduction of contraception being prescribed at pharmacy level. In response to service quality, it was reported that if patients were not receiving good quality care and service they would find alternative provision. Finally, there was a need to demonstrate the skills that pharmacists had for lower acuity conditions and for health professionals to refer to a pharmacist rather than a GP and in turn that would build confidence in referring more high acuity cases to pharmacists.

In relation to Public Health and reducing health inequalities, community pharmacies were seen as an excellent resource to highlight conditions and alert patients which would in tun improve the lives of residents.

The Cabinet Member with Responsibility for Health and Well being commented on the very enlightening discussion. The HOSC Chairman agreed and invited an update at an appropriate time in the future and following the transition from NHSE to HWICB.

The meeting was adjourned from 12pm to 12:10pm.