By Alexander Humphries*

When most children were writing their letters to Father Christmas, a boy called Keith furiously scribbled a wish list of his very own...

Keith didn't want a remote controlled drone or an adult mindfulness colouring book. What he wanted was something even more expensive – a radical, top-down shake-up
of community pharmacy. But wait... weren’t we promised no more top-down reorganisations of the health service? Clearly pharmacy doesn’t count as ‘health’ – or even as primary care.

That now infamous December letter from the Department of Health and NHS England reads like it was concocted at the DH Christmas party after Wendy from admin spiked the punch. Confused, muddled and jumbled are just some of the words I’ve heard used to describe this car-crash of ivory tower thinking. I’d say NHS England’s Grinch Squad sent the letter a week before Christmas to try and take the sting out of the sector’s fury by ensuring nobody could react immediately. So what does the letter really mean?

It starts by telling us the Five Year Forward View sets out a clear direction. If you’re not familiar with the detail of the 5YFV, let me summarise: transformational change (aka ‘making things work like America’, and by work, we mean financially, not from a healthcare perspective) is the way forward (and by ‘way forward’ we mean in reality ‘wind backward’).

Making efficiencies

The bit in the letter getting the most attention is the section entitled ‘Making efficiencies’ (cuts, in other words), which says pharmacy funding for 2016/17 will be no higher than £2.63 billion (down from £2.8 billion). Put another way, that amounts to a 6 per cent cut.

Community pharmacy, we are assured, is a core part of NHS primary care. So core that we aren’t even in the primary care budget. That is reserved for general practice, which is getting a 4 per cent annual pay rise over the next five years.

What we are getting instead is a Pharmacy Integration Fund and a Pharmacy Access Scheme – both short on detail – and could be anything from a sticking plaster on a broken leg, right up to being the catalyst for systemwide change. Who knows?

Slow and awkward

The letter says the DH will consult on how best to drive new models of ordering prescriptions and collecting dispensed medicines, pointing out that “the online journey for patients remains slow and awkward”. We know. We have to deal with terrible general practice systems everyday.

Hub and spoke dispensing, we are told, “could help pharmacies to lower their operating costs and free up pharmacists to provide more clinical and public health services”. Or not. Anyone who has worked in a pharmacy will tell you that most of their patients’ repeat scripts are unsynchronised – they run out at different times, which wrecks the efficiency argument.

Let us be clear: this is a race to the bottom over the cost of supply and there will inevitably be patient safety implications. Automation isn’t the golden goose of safety; it has every possibility of going wrong. The meltdown at Pharmacy2U over Christmas shows just how problematic putting all of your eggs in one basket can be.

Disastrous

The real danger in all of this nonsense lies in the impact on competition in the pharmacy sector. If the effect of cutting funding and introducing various other measures is to reduce the number of pharmacies and competition between those pharmacies, then the effect could be disastrous for the public.

Pharmacies compete against each other to provide better, cheaper services. This has delivered huge gains for the public and massive reductions in drug costs. And it is not the big boys who drive this. It is the diverse and vibrant small and medium-sized businesses offering free services such as collection and delivery and extended hours that the Government doesn’t actually pay for directly.

Yes, there are probably too many pharmacies in some urban centres like London, Manchester and Birmingham – but this was driven by decisions taken in Whitehall by the same people who are now telling us there are too many pharmacies. The Government doesn’t want to lose 100-hour pharmacies and seems unwilling to tackle bogus or even poorly performing internet pharmacies.

So, in essence, the letter was about two things: a funding cut and pharmacy’s direction of travel. Both appear bleak indeed.