When a woman recently walked into Thorrun Govind’s high-street pharmacy in Bolton seeking help for a common infection, Govind quickly knew what to prescribe. But because the woman said she had not had the medication before, Govind had to check with her GP practice. They insisted the woman go in.
The anecdote sums up the frustration of many of the UK’s 14,000 community pharmacists that they are not being allowed to do more to ease the pressure on NHS services, despite repeated assurances by ministers and officials that they want them to do so. The health secretary, Jeremy Hunt, told the NHS Confederation conference in June: “I feel we haven’t exploited the tremendous skills that pharmacists have nearly as effectively as we might.”
New research, the first of its kind, suggests that pharmacies could make a much more effective contribution to tackling health inequalities if the commissioning of public health services by local councils was more consistent and targeted on need.
Certain services, including those covering help to stop smoking, sexual health and needle exchanges for drug users, became councils’ responsibility in England in 2013. Annual funding has since been cut by £531m – including a highly controversial in-year reduction of £200m in 2015-16 – but the research reveals widespread disparities in how the money is used and whether it is spent in line with known patterns of ill health. “This study reveals a mismatch between the health needs of local populations and the services commissioned, which is concerning,” says Robbie Turner, the Royal Pharmaceutical Society’s director for England.
The research has produced the first map of services commissioned from pharmacies across England. Using freedom of information requests, a joint team from Liverpool John Moores University and the Medway School of Pharmacy , based at the universities of Kent and Greenwich, compiled data from 97% of councils and tracked a total of 833 services commissioned in 2014-15.
Almost all councils commissioned at least one sexual health service – the most common being emergency hormonal contraception, or the morning-after pill, and chlamydia screening and treatment. All of them commissioned supervised consumption of methadone or another drug substitute. However, only 47% of pharmacies were appointed to provide the morning-after pill and only 52% provided supervised consumption of drug substitutes.
Nearly half of English pharmacies provided services to help people to stop smoking, the most frequently commissioned “lifestyle modification” service. But fewer than one in three councils commissioned NHS health checks, barely one in five an alcohol service – and just six out of the total 148 surveyed were paying for weight management advice and support.
The researchers established that of the 14 councils that did not commission a smoking cessation service, seven of them had higher smoking rates than the national average. Of the 48 councils that did commission NHS health checks, 31 were in areas with below-average diabetes rates and 29 had below-average death rates from heart disease.Meanwhile, only six of the 30 areas that had the highest heart disease death rates commissioned health checks – and just nine of the 22 councils commissioning alcohol screening had above-average rates for drink-related hospital admissions.
Published by the online medical journal BMJ Open, the study concludes that the commissioning of services is “poorly correlated to potential need”. While reasons for this are not clear and require investigation, the team says, the findings indicate that councils should take a more strategic approach when deciding how best pharmacies can help improve public health, perhaps employing regional or national approaches.
This message has been well received by the pharmacy sector. Helga Mangion, policy manager of the National Pharmacy Association and a practising pharmacist, says: “Local pharmacies have a long track record of health improvement, but we want to be engaged more thoroughly to address identified need, including in deprived communities.”
In Bolton, Govind is passionate about doing more. Aged 24 and qualified just a year, she represents a new generation of pharmacists who see the future of the profession as much more closely integrated with the broader health and care system and want greater recognition of their skills.
“People say, ‘I’ll go to the GP about this.’ They don’t understand that we have a consultation room, I am fully trained and, if I have their consent, I can access their summary care record and get a note of the medicines they have. I have all the tools.
“It costs the NHS £45 for a GP appointment, plus the cost of dispensing the medication and the cost of the drug itself. If a minor ailments service was commissioned from community pharmacies nationally, it would save a lot of money and take a lot of pressure off the system.”
Typically, a pharmacy is paid £12 for each morning-after pill dispensed, £10 for each vaccination against hepatitis B and £2 for each supervision of methadone consumption (plus reimbursed cost of the medication in all cases).
Govind works for the Lancashire-based Sykes chain of pharmacies. Of its 18 branches, she says only two are commissioned to provide a minor ailments service. All offer the morning-after pill, but whether it is free depends on the local council’s commissioning arrangements. In contrast, women in Wales and Scotland can obtain emergency hormonal contraception free at pharmacies, but the Westminster government continues to resist pressure to extend the right across England and women face paying up to £30. Some Sykes branches are commissioned to offer chlamydia screening, she says, while “most” offer supervised methadone consumption.
Adam Mackridge, the study’s co-author and reader in public health pharmacy at Liverpool John Moores, says: “With in excess of 1 million people visiting a community pharmacy every day, they have long been championed as a potential setting for the delivery of public health services to local communities. At the moment, this is not matched well enough to potential need and so we may be missing opportunities to support health and wellbeing. For example, we know that NHS health checks and screening for risky alcohol use are not available in many areas with significant potential to benefit.”
One of the big arguments for making more use of high-street pharmacies is that at least 95% of people living in the most deprived areas live within 20 minutes’ walk of a pharmacy. Cuts to pharmacies’ national funding, which the Pharmaceutical Services Negotiating Committee says leave them with 7.5% less money this year than in 2015-16, could force closures that imperil that reach – especially in poorer communities where across-the-counter spending is low and cannot cushion such a reduction.
Izzi Seccombe, chair of the community wellbeing board at the Local Government Association, which represents councils, says: “Pharmacies have the potential to play a critical role in improving the health of communities by offering convenient and equitable access to health improvement services. But we are clear that community pharmacies themselves need to change and do more to explain what they can offer to local public health commissioners.”