Opinion: Coping with closures

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The last 12-18 months have seen a host of pharmacy closures. Some might be seen as rationalisation of local over-provision, while others definitely leave a gap in care.

The primary impact of any closure is obviously felt mainly by the pharmacy owner affected, who is seeing the demise of what they once saw as a financial resource. It also affects the patients the pharmacy served, who may be losing an important relationship built up over years and may now find access to a pharmacy more difficult.

The impact of closures is also felt by other pharmacy contractors locally. You might be forgiven for thinking that losing a business competitor would be a good thing. However, if this is not managed, it can put great pressure on the remaining pharmacies in the area. It can create problems for delivering clinical pharmacy services and, with the change in focus of the remuneration model from supply to service, it can put increased pressure on achieving pharmacy business success.

What happens next?

When a pharmacy closes, patients obviously have to go to different pharmacies, hopefully nearby, to have their prescriptions dispensed. These pharmacies often face capacity issues when dealing with this extra workload in terms of staff time and even the need for more physical space. 

There is also typically a negative impact on cash flow because of the increased cost of purchasing the drugs needed to dispense these additional prescriptions before the pharmacy is reimbursed by the NHS.

Pharmacy owners often find it difficult to invest to meet these pressures as they cannot be sure that any changes will not prove transient. The lack of certainty about pharmacy services has been a barrier to investment for a while. Even if a community pharmacy employed extra staff to manage the increased workload, it would take some time for them to become productive.

When a patient brings a prescription to a pharmacy, that pharmacy is contractually required to dispense the prescription. Dispensing is an essential service and clinical offerings, in the main, are advanced services. The increased dispensing workload, requirement to dispense, lack of certainty and lack of increased investment all has the effect of squeezing out the provision of clinical pharmacy services.

This lack of ability to deliver services has a further impact on patients, who cannot access them. It has an impact on local GP practices, who do not benefit from pharmacies taking on workload to allow them to focus on patients who have a greater need. This in turn has an impact on secondary care because it cannot rely on GPs managing some of these patients.

There is also reputational damage to pharmacies. If patients do not receive the services that GP practices have referred them for, the patients will be disappointed. Practice staff will also be annoyed because of their wasted effort and be less inclined to refer patients to pharmacy in future.

Reconsider needs 

Integrated care boards need to reconsider pharmaceutical needs assessments to include the totality of the pharmacy service expected within a locality. 

This should, of course, include dispensing, but also all the other services that should be provided by pharmacies: Pharmacy First, hypertension case-finding and oral contraception, to name a few. It would provide a strategic blueprint for how pharmacy can be integrated effectively with primary care partners and give contractors a clearer understanding of what is expected of them in the future. This may encourage them to invest in their pharmacies. 

ICBs also need to consider how they manage the closure of local pharmacy contracts. At the moment, it seems to be left to market forces, but this is not the way the closure of a GP practice would be managed. The ICB should consider the implications of any pharmacy closures and take actions to ensure that patients are not deprived of a full range of pharmacy services.

“We should also think about a capitation model for pharmacy”

Perhaps – controversially – planners also need to think about a capitation model for pharmacy. Contracting to service a fixed population would move pharmacy away from the race to increase dispensing piecework, and focus on providing a broader pharmaceutical service for local communities. 

It would allow pharmacies to turn away new patients from the dispensing service if they are at capacity to avoid an impact on clinical services. However, caution is certainly required with a capitation model to avoid losing pharmacy’s chief benefit of accessibility. 

Some might argue that these measures restrict business flexibility in community pharmacy – and I would agree. But they would also bring certainty and consistency. For me, that outweighs the cost.

• Liam Stapleton is director of Metaphor Development Limited and an associate clinical lecturer at the University of Lincoln.