Pharmacy in Scotland: ambition, reality and difficult choices

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Spend any time in a Scottish community pharmacy today and one thing becomes immediately clear: this is no longer simply a place to dispense medicines. It is a front door to the NHS. A growing clinical hub in its own right.

That transformation is something the profession – and partners such as the Scottish Government – should be very proud of. Over the past decade Scotland has made deliberate choices to invest in a more clinical, accessible model of care, with national services like Pharmacy First and a clear trajectory towards independent prescribing embedded at scale.

But there is a harder truth sitting just beneath that progress. The model is being stretched.

And, increasingly, the conversation across the UK is not about what community pharmacy can do – but whether the system is set up to support what it is already being asked to deliver.

A shared challenge — but not a uniform experience

Across England, Wales, Northern Ireland and Scotland, community pharmacy is operating under sustained pressure. Demand is rising, workforce challenges persist, costs are increasing, and medicines supply has become more volatile.

These pressures are common. But what differs is how each system has chosen to respond – and how those choices are now playing out.

In England, much of the debate has focused on the adequacy of the core contractual framework and whether it has kept pace with inflation and activity.

Wales has taken a more overtly developmental approach, investing in clinical services and reform, albeit within constrained financial limits, while Northern Ireland continues to face very significant challenges around both funding and workforce stability.

Scotland sits in an interesting place within that landscape.

It has arguably been one of the most ambitious countries in defining the future role of community pharmacy – particularly in its commitment to universal service models and prescribing. But that ambition is now running up against a financial and operational reality that cannot be ignored.

Growing demand, fixed resource

From a Scottish perspective, the direction of travel is clear: pharmacies are seeing higher consultation volumes, greater clinical demands, and increasing expectations from both patients and the wider system.

This is not temporary. It reflects a deliberate policy shift – more care delivered in the community, more reliance on multidisciplinary teams, and a recognition that pharmacy is a critical part of the solution to wider NHS pressures.

But while expectations have expanded, the underlying funding and operating model has not evolved at the same pace. That creates a structural tension.

Pharmacies are being asked to do more – and are doing more – but within a financial framework that was not designed for that level of activity or complexity. Over time, that gap increases.

Market volatility

Overlaying this is a more structural challenge that is increasingly shaping the sustainability of the network – the medicines market itself.

Recent experience has shown just how exposed community pharmacy is to volatility in tariffs, global supply disruption, and reduced purchasing margin. These are not marginal issues.

They affect day-to-day cashflow, increase workload through sourcing and substitutions, and introduce financial risk that contractors are largely expected to absorb. Importantly, they also sit outside the direct control of individual pharmacies.

Unlike most sectors, pharmacies have very limited ability to offset these pressures. The NHS is the primary customer, pricing is fixed, and there is little scope to pass on increased costs.

The result is a model where risk sits increasingly with the network – without a corresponding shift in how that risk is recognised or supported.

It would be easier if these challenges were discrete – but in reality, they are cumulative.

Alongside medicines market pressures, the network is dealing with rising workforce costs, increases in employer National Insurance, ongoing service demand growth, and operational complexity linked to supply disruption.

Taken individually, each is manageable. But taken together, they create sustained and compounding pressure on viability. That is not a stable long-term position.

A question of system design

Some of the issues facing Scotland’s network are not simply financial – they are structural.

For example, the way premises costs are treated differently from other parts of primary care raises broader questions about consistency and fairness within the system. More broadly, there remains a gap between policy ambition and system design.

Expanding services without addressing underlying capacity and sustainability risks undermines both resilience and patient access.

None of this is to diminish what has been achieved. Community pharmacy in Scotland remains one of the most accessible and trusted parts of the NHS. It is already delivering significant value – for patients, for health and social care partners, and for the wider system.

The opportunity now is to build on that foundation – but that next phase will require honesty.

If the ambition is to expand prescribing, increase the role of pharmacy in prevention and long-term conditions, and continue to shift care into the community, then the enabling conditions must be in place.

That means greater stability in funding, recognition of medicines market risk, alignment between expectations and resource, and investment in workforce and integration.

UK-wide lesson

While I have focused on Scotland, the underlying question applies across all four nations. Community pharmacy has demonstrated, repeatedly, that it can do more.

But there is a limit to how far any system can stretch without recalibration. From my perspective, the conversation we need to have is a simple one – even if the answers are complex.

Are we clear about the role we want community pharmacy to play? And if we are, are we prepared to put in place the conditions that allow it to succeed?

Because if the answer to that second question is uncertain, then the real risk is not that pharmacy does not do more. It is that, over time, the system asks too much and finds that the capacity it relies on is no longer there in the way it once was.