Moved by Lord Hunt of Kings Heath
At end insert “but that this House regrets that the Order does not make provision about the wider workforce challenges facing the community pharmacy sector”.
My Lords, I certainly have no objection to this statutory instrument, which, as the Minister said, requires a strengthening of the governance that relates to superintendent and responsible pharmacists. My complaint is that this could have been so much more. My principal purpose in tabling my amendment and allowing us to debate this is to talk about the potential of community pharmacy and my frustration that the Government are doing so little to support the sector. I find that quite extraordinary.
As the Minister said, the NHS is going through an incredibly tough time. We have a huge backlog of patients waiting for treatment, workforce pressures, scary ambulance waiting times, and there is a real sense of demoralisation in primary care. You would think that the Government would have welcomed with open arms the contribution that community pharmacy can make. Instead, however, it seems that the sector continues to be undervalued and starved of investment.
The contribution that community pharmacies made during the pandemic was really extraordinary. As noble Lords will know, hospitals were very much focused on Covid. They were taking great precautions and were sometimes unable to deal with patients needing routine and sometimes urgent treatments. In primary care, it was very difficult for patients to obtain face-to-face appointments. Through all this, the only reliable, accessible part of the NHS that you could go to see, face to face, were the community pharmacists. We should pay great tribute to them. It is noticeable that there was an increase of nearly 40% in the number of people visiting community pharmacists during the pandemic.
I also pay tribute to the role of community pharmacies when it came to the rollout of the vaccine. The Company Chemists’ Association reckons that they have delivered more than 24 million vaccines to date, which is a tremendous feat. The Pharmaceutical Services Negotiating Committee estimates that around 1.6 million people visit a community pharmacy every day in England, and say that that saves about 32 million appointments per year to general practitioners.
As the PDA says, we now understand that the pharmacy can provide a much more comprehensive contribution to health care than was ever contemplated in years gone by. Thinking about the future, and how pharmacies could play a central role in new multi- disciplinary working in primary care, this could be a real game-changer for co-ordinated primary care, given the silo working that we have seen consistently in that sector over the years.
I acknowledge that some of that is recognised by the Government. The Minister himself paid tribute to community pharmacies today. I should say that the NHS Long Term Plan promised to make greater use of community pharmacists’ skills, and new clinical services have been introduced. I particularly welcome the Community Pharmacist Consultation Service, where staff in general practice and NHS 111 can refer patients to community pharmacies for advice on and treatment of minor illnesses. That is very welcome indeed, but we need to build on it. We must recognise that, at the same time, community pharmacy is absolutely hamstrung by workforce pressures and budgetary austerity, which threatens the viability of some parts of the sector, and certainly its ability to take on a much greater workload in future.
On funding, the Company Chemists’ Association reckons that the last increase in funding was in 2014. However, it was then cut by around £200 million a year in 2016, and the current contractual framework agreed in 2019 has not been adjusted, despite the pandemic and rising inflation. An analysis by the CCA shows that per capita spend in the community pharmacy sector decreased by nearly 10.7% from 2014 to 2019. As the PSNC says, it is clear that pharmacies are proving themselves, time and again, to be the most accessible healthcare locations, helping patients with a wide range of increasingly complex conditions and needs. It is astonishing that this work is all being done without specific funding.
The Minister was a little unsympathetic when it came to workforce issues. He seemed to be saying that because community pharmacies are essentially commercial businesses, workforce issues are their responsibility. Given that the great majority of income for community pharmacies comes from their work on NHS dispensing, you cannot divorce the viability of community pharmacies from the funding that the Department of Health makes available—and of course that impacts on the workforce.
The Minister said that the situation is being monitored and suggested that this was more a geographical disparity than a general problem. However, there are a record number of pharmacy vacancies, and we know that many of the businesses are struggling to recruit because of a number of related issues, such as a reduction in the number of students, Brexit and pharmacists choosing to work elsewhere. I am not opposed to this. The movement of some community pharmacies into GP surgeries and primary care networks is a good thing, but there is still a huge role for the community pharmacy sector on the high street as well.
There is a risk here. We have seen during the pandemic that community pharmacies can do more. They certainly have the professionalism and skills to take on more responsibility. However, the combination of funding and workforce pressures makes it unlikely that they can take on these new roles to the extent that would be extremely desirable in an NHS which is very hard-pressed and which will continue to be hard-pressed over the next few years.
My main message to the Minister is this: surely there is now a case for Ministers setting out a long-term vision for community pharmacies, placing them at the heart of primary care and ensuring that there is funding and workforce support to enable this to happen. Given the tremendous pressure on the health service, we have a huge untapped resource which we must fully encourage to do all it can to support patients at a very difficult time. I beg to move.
My Lords, I congratulate my noble friend on bringing forward the order before us today. I am interested to understand the background to why we are moving from ministerial discretion to regulated control. I think my noble friend will assure the House this afternoon that the concerns raised by the Secondary Legislation Scrutiny Committee have been addressed and that any changes will be brought forward by statutory instrument, in which case the committee and the House will have the opportunity to look at them.
I join the noble Lord, Lord Hunt, and my noble friend, in paying tribute to community pharmacies for the work that they have done throughout the years, and particularly during the Covid pandemic.
What will the position of dispensing doctors be, who fulfil a role where community pharmacies do not reach? Quite a large network of rural areas is served by dispensing doctors. As the daughter and the sister of dispensing doctors, and as someone doing outside work with dispensing doctors, I think it is appropriate that we look at how they are potentially being asked, for example, to deliver a booster jab this autumn at the same time as the flu jab. That will pose enormous logistical challenges for community pharmacies, dispensing doctors and others. How do my noble friend and his department expect to address those challenges so that the rollout will go as smoothly in the autumn—particularly if it is combined with a flu jab—as it did in the previous three or four rounds?
My Lords, the health or otherwise of independent community pharmacies can be judged by the rate of closures, which has been increasing over the last few years for a number of reasons, not least the overall deal with the NHS. That deal requires, for example, an individually owned community pharmacy to be deemed to have received the same discount on the purchase of drugs that Boots and the other big chains get on volume discounts. There is a serious crisis in this sector. Can my noble friend the Minister give us some idea of the rate of closure? If he does not have the statistics today, perhaps he could place them in the Library. Closure is an upward trend.
My Lords, I thank the Minister for his introduction to this Order and the noble Lord, Lord Hunt of Kings Heath, for explaining his amendment. First, as others have said, it is important to recognise the contribution pharmacists in our health service have made for many years—long before the NHS was created. Too often we talk about clinical and health care professionals and do not raise the vital contribution made by pharmacists. Covid-19 has really demonstrated in a number of ways that they are not only a cornerstone of the NHS and our healthcare system. In the pandemic, and lockdown especially, they also stepped up, took on extra responsibilities and became a new frontline service for people concerned about minor symptoms that they would normally have taken to their GPs, while their GPs were overrun with many more serious cases, including Covid cases.
I too thank the PSNC for the pharmacy advice audit it sent through earlier this week. We now know that nearly a quarter of a million consultations a week—that is 65 million informal healthcare consultations a year—are still being carried out in community pharmacy because patients are unable to access another part of the healthcare system. We should not forget, either, that the pharmacy database was used as the basis for the NHS app because it already had direct links with GP records, prescriptions and vaccinations that were delivered by pharmacists in their pharmacies.
Turning to the SI, which clarifies the governance of, and sets out the roles of, responsible pharmacists and superintendent pharmacists, the brief summary by the Secondary Legislation Scrutiny Committee raises some key issues. The Minister is right: although there are only three paragraphs, its report is certainly worth reading. It says in paragraph 14:
“several proposals were not popular with respondents to the consultation exercise on the grounds that they may reduce patient safety, particularly provisions allowing Superintendent Pharmacists to cover more than one firm and Responsible Pharmacists to cover more than one pharmacy or to operate remotely. We also note significant levels of distrust from the profession that the regulator, the General Pharmaceutical Council … would be able to set standards and rules appropriately.”
Worryingly, the committee goes on to say:
“We found the response of the Department of Health and Social Care … to these concerns, as set out in the Explanatory Memorandum, unconvincing.”
In the next paragraph, it says:
“In supplementary material, DHSC told us that to counter the concerns the GPhC will be required to consult on any proposed rules, which will provide the profession with an opportunity for scrutiny and comment. In addition, any changes to professional rules made … would need to be made by a statutory instrument following the negative resolution procedure in Parliament.”
Although this extra information to the Secondary Legislation Scrutiny Committee is reassuring, I still want to ask the Minister what the timescale is likely to be before such an instrument is laid before Parliament for scrutiny, explaining those concerns outlined by the committee and how they will be alleviated.
I thank the General Pharmaceutical Council for its briefing, which sets out the safeguards in the draft order to consult on the rules and report back. I know we look forward to seeing the detailed responses to the consultation and how they might affect the resulting resolution. With any change in responsibility, trust is absolutely critical, and this is on top of the increase in community consultations and referrals to other parts of the healthcare system that pharmacists throughout the UK are now carrying out. This is the real change already happening in our primary care system that Ministers say we should be looking for, and the public have taken to it.
The All-Party Pharmacy Group notes that the new demands on pharmacists have been coupled with a real-terms decrease in funding over the last eight years. Despite their desire to help, many pharmacies have had to limit or reduce their offerings and, as the noble Lord, Lord Hunt, has said, some pharmacies are closing. It is in this context that the noble Lord has brought forward his amendment, asking your Lordships’ House to consider that
“the Order does not make provision about the wider workforce challenges facing the community pharmacy sector”.
We echo that sentiment from these Benches. The noble Lord’s speech explained many of the problems the pharmacy sector faces, which I will not repeat, and he is right that the PSNC is doing everything asked of it but the system—funding and workforce—is not backing up the role of pharmacists that everyone wants to see. So I ask the Minister the following questions. What assessment has he made of community pharmacy closures and is there a plan to adapt the funding model to prevent any further losses? Will the Minister recognise the value of increasing independent prescribers and commit to a funding plan that supports training for both existing and new pharmacists to become independent prescribers? Does the Minister also agree that integrated care systems should consider pharmacy workforce planning across all sectors of health and social care? Will the Minister confirm whether the department is working on a long-term plan for pharmacies? If so, when will it be published?
The Minister knows that, during the passage of the Health and Care Act, amendments supported across your Lordships’ House sought to place a duty on the Government to plan and publish key workforce plans for all parts of the NHS. Our pharmacy sector, especially community pharmacies, is stepping up to its new responsibilities, despite decreased funding year on year, increased roles and taking over part of the front-line consultation with the public. Without a clear workforce plan for the pharmacy sector, the Government are setting it up to fail. That is why, if the noble Lord, Lord Hunt, decides to press his amendment to a Division, our Benches will support him.
My Lords, this debate has been a welcome opportunity to clarify the role of responsible and superintendent pharmacists, as set out in the SI, and to take a closer look at the wider industry, its workforce and, in particular, the support and funding community pharmacies need to enable them to operate effectively and undertake the extended role they need as an integral part of the local primary care team.
I congratulate my noble friend Lord Hunt on his excellent speech and presentation of the strong case for his amendment. All speakers have rightly paid tribute to the role played by community pharmacies during the pandemic, which remained open and continued to offer their full range of services. We all acknowledge the huge contribution they made then and make now to front-line care: the delivery of mass vaccination programmes for both Covid and flu, providing essential preventive programmes, such as blood pressure checks, providing medicine support for patients discharged from hospital, and supporting patients, particularly those with long-term conditions, with their self-care and self-management. All this takes pressure off GPs and ensures better access for patients to healthcare information and advice, and more efficient use of NHS resources. The estimate that the NHS could save £640 million through nationwide treatment of minor ailments by community pharmacists is an example of how their role should be extended.
The new community pharmacy consultation service mentioned by my noble friend Lord Hunt—involving GP surgeries, NHS 111 and pharmacies—for minor illness or medication consultations, and the pilot schemes for NHS Direct cancer referrals to pharmacies for patient scans and checks, are both key developments which we very much welcome.
I also pay tribute to my colleague Peter Dowd MP for his excellent Westminster Hall debate last week, which I commend to your Lordships. It set out a compelling case on the contribution community pharmacists could make with the right support and funding and increased collaboration with GPs, a case which had strong cross-party backing from supporting speakers. However, no part of the extended role we all want to see can be delivered unless the major workforce issues across community pharmacies are acknowledged, and the ongoing discussions with the Pharmaceutical Services Negotiating Committee on the current agreement and future funding acknowledge the scale of the resources needed.
On the SI, we support and welcome the aim of clarifying and strengthening the governance requirements of responsible and superintendent pharmacists. I thank the General Pharmaceutical Council for the reassurances in the note it prepared for this debate on extensive public consultation and engagement with patients, the public and the pharmacy and health sector on the rules and standards to operate under the extended remit the SI gives them.
Like my noble friend and the noble Baroness, Lady Brinton, I await the Minister’s response to the concerns of the Secondary Legislation Scrutiny Committee on the profession’s general distrust of the council on the setting of appropriate standards and concerns about patient safety if the pharmacist is absent from the pharmacy. As the committee rightly stressed, the Government need to improve on the reassurances they offered the committee. How are the profession’s concerns and reservations to be addressed? How will the Minister address the Pharmacists’ Defence Association’s deep worry that the new focus of the GPC in exercising its rule-making powers, minimising the burden on businesses, could lead to less focus on patient safety, which surely must be the council’s number one concern?
On workforce, all the excellent stakeholder briefings we received for this debate point to a crisis across the pharmacy industry. While the numbers of pharmacists on the register and of pharmacy technicians have increased, there has been a serious reduction in the numbers of students in training and of dispensary and counter staff. As we have heard, the primary care networks, with pharmacists working in GPs’ surgeries and away from pharmacies, have had a significant impact on staffing levels in high-street pharmacies, which to cover vacancies have to make increasing use of locums, the cost of which is spiralling. The Company Chemists’ Association’s estimate of a shortfall of 3,000 community pharmacies in England is not the setting or context in which any newly extended role for community pharmacies can develop strongly and flourish.
There is also the PDA’s serious concern about the pressures on staff in some pharmacies, such as unsafe staffing levels, poor pay and working conditions, long hours and suffering physical abuse from customers, which cause them to want to change jobs or leave the profession. What are the Government doing to ensure that risk assessment and preventive safety measures are in place, as well as a zero-tolerance approach when incidents occur? How can the welcome development of primary care networks and pharmacy services in GP surgeries develop hand in hand with ensuring enough staff and resources for community pharmacies to provide the quality of professional care that they want to deliver and we all want to see? How will the Government help pharmacies invest in staff training and development?
On funding, the Minister will have heard the concerns from across the House. The CCA’s estimate of funding last being increased for the sector eight years ago, in 2014, and the cuts of £200 million that it had to find two years later, paint a sobering picture of how the industry has fared. The current community pharmacy contractual framework agreed in 2019 has not been adjusted despite the pandemic and rising inflation and costs. The £370 million from the Government to meet pandemic costs was a loan, as we know from valiant attempts in this House to ensure that the industry did not have to repay it. I understand that it was repaid and then a separate admin process was established for the industry to claim back the extra costs incurred during Covid. Does the Minister have any further information on the sums reclaimed under this procedure? Can he reassure the House that the current negotiations with the PSNC on year 4 of the five-year funding agreement will include funding recognition for the extended and full role that community pharmacies need to play?
The need for an overall strategy for the primary care workforce across GPs, pharmacies and community services becomes ever more urgent, as this debate and the questions from noble Lords have clearly demonstrated. I look forward to the Minister’s response. We will fully support my noble friend’s amendment, should he put it to the vote, highlighting the vital importance of having the clear, long-term strategy and vision for community pharmacies that we have all been calling for.
My Lords, I thank all noble Lords for their contributions and once again apologise for the delay in bringing this matter before the House. I welcome the essential role that your Lordships play in scrutinising measures. I experienced that during the passage of the Health and Care Bill, and I think we have a better Act as a result of the scrutiny from across the House. I will try to address as many as possible of the points raised before I conclude. I will try to cover most of the points but I pledge to write to noble Lords if I have missed any specific points.
If we look at the overall picture of the NHS, I am sure noble Lords recognise that we seem to have more doctors, nurses and pharmacists than ever before. As someone said to me the other day, that is all very well but the supply is not keeping up with the demand. If we consider our whole understanding of health, some of the things we ignored many years ago are now things we deem as needing treatment. For example, the whole area of mental health was ignored for many years. PTSM, which people talk about now, was officially recognised only in the 1980s. I know that we will probably talk about that in the next debate.
Before a debate the other day about neurological conditions, I asked my officials to give me a list of all the conditions. They said, “Minister, there are 600 of them.” Let us think about this. We were not even aware of that previously. It shows the great complexity as we become more aware of conditions and issues, putting even more pressure on our health service and health professionals, even though we have more health professionals than ever before.
The Secretary of State recently pledged to start with pharmacies when it came to overall primary care. The community pharmacy contractual framework, to which the noble Baroness, Lady Wheeler, referred—the 2019 to 2024 five-year deal—set out a joint vision for the sector, and an ambition for community pharmacies to be better integrated in the NHS and provide more clinical services. We saw this during the pandemic when pharmacies provided vaccines and we have seen recently that they will be providing more initial advice on issues such as cancer—and they welcome this.
At the same time, we are seeing an overhaul of the overall model. It is time to move away from the old model, in which you see your GP for five minutes and then hope for a referral somewhere else. Services previously considered part of secondary care are now being taken over by primary care centres. Areas previously considered the work of GPs are now being taken over by nurses and physiotherapists, as well as by pharmacists in the community.
Despite the challenges of the last few years, we have jointly delivered the introduction of a new range of clinical services at the community level. These are important in their own right and we are negotiating with the Pharmaceutical Services Negotiating Committee on the expansion of additional services to be introduced in the fourth year of the five-year deal. I very much hope that my right honourable friend the Secretary of State will be able to make an announcement soon. Longer term, we want to build on what has already been achieved and make better use of existing skill sets and those that are developing; for example, the prescribing and assessment skills that all pharmacists graduating from 2026 will have acquired during their training.
I turn to some specific points. We now have more pharmacists than ever before. Data from Health Education England shows that we now have an additional 4,122 pharmacists employed in the community compared with 2017, and the number of registered pharmacists has increased year on year. The number of primary care pharmacy education pathway trainees coming from community pharmacy increased by nearly 2,500. Reforms to initial education and training of pharmacists means that pharmacists qualified from 2026 will be qualified to prescribe at the point of registration. On top of the £2.5 billion that we are spending on the sector, Health Education England is investing £15.9 million over the next four years to support the expansion of front-line pharmacy staff in primary and community care.
We are also supporting a significant expansion in primary care capacity through the additional roles reimbursement scheme, enabling primary care networks to recruit clinical pharmacists and pharmacy technicians, two of 15 roles that PCNs can choose to recruit to. We saw the strength and potential of community pharmacies —many noble Lords referred to it—during the Covid vaccination campaign and the role that community pharmacies played in it. It is not yet known whether recurrent boosters will be required annually. We are looking into that and whether pharmacies will be once again called on.
Noble Lords will recognise—we had this debate many times during the stages of the Health and Care Bill—that to support long-term workforce planning, we are looking first at the long-term strategic drivers of workforce demand and supply. Building on this work, we have commissioned NHS England and NHS Improvement to develop a long-term plan for the workforce for the next 15 years, including long-term supply projections. Once this work is ready, we will share the conclusions and start to home in on what it means for recruitment, skills needed and skill gaps.
A number of noble Lords raised fears or concerns about what the regulators will do with their new powers. This is understandable: community pharmacies are private businesses and increased regulatory burden will be a concern for many of them. However, once again, we have to get the right balance between regulation and making sure of safety. The proposals include safeguards to ensure that any changes the regulators make are subject to full consultation, in much the same way as is expected from the Government. This will ensure that patients, the public, pharmacy professionals and the pharmacy sector have their say on what the standards should say.
There were some concerns about remote supervision. It is important to emphasise that a lot of the issues raised today do not affect this legislation, but I completely understand the point about taking advantage of the situation to debate the wider issues.
Many noble Lords have asked about the role of primary care networks. One of the tensions that we have is that in some parts of the network we have seen an expansion in primary care capacity through additional roles, but there are accusations—or tensions—that PCNs are poaching community pharmacies, and we are asked what the Government can do. We want to make sure that we address that tension to ensure that the approach is appropriate. Of course PCNs need pharmacies, but at the same time what pressure does that put on community pharmacies? At the end of the day, it is important that patients and others have access to a pharmacy within a close distance.
I turn to issues raised by other noble Lords. My noble friend Lady McIntosh talked about dispensing doctors. I apologise: I should have foreseen that question, and I commit to writing to my noble friend. On the rate of closures, I commit to writing to more than one noble Lord who asked about that, and I will get that data.
On the timeline, even I find this slightly unhelpful, but I will read out what I have been advised: the timeline has been brought forward by regulators and they are going to outline the programme of work, but I do not yet have specific dates. As soon as I have specific dates from the regulators and the timeline, I commit to writing to noble Lords.
In closing, I am grateful for the contributions from noble Lords today. Introducing the order will give pharmacy regulators the necessary powers to set standards and rules on pharmacy practice matters and the core roles of responsible pharmacists and superintendent pharmacists. We hope this will allow the rules better to keep pace with the changes in modern pharmacy services. We recognise what was highlighted by the Secondary Legislation Scrutiny Committee’s first report, and any subsequent draft rules produced by the regulators will require full public consultation and scrutiny by Parliament. We look forward to discussing these matters in debate.
I turn to the amendment in the name of the noble Lord, Lord Hunt. Of course I have sympathy with the issues that he has raised. Strictly speaking, they are not matters that can be addressed by the legislation before your Lordships’ House today, so while I understand the frustrations, I do not support the noble Lord’s amendment. I thank Members for their interest and for the positive debate today and I commend the order to the House.
My Lords, I am grateful to noble Lords who have taken part in the debate and to the Minister. The noble Baroness, Lady McIntosh, was right to raise the concerns of the Secondary Legislation Scrutiny Committee. I was reassured by the briefing we had from the General Pharmaceutical Council. Clearly, it is something we need to keep a watch on.
As far as timelines are concerned—and I declare an interest as a member of the GMC—the Minister will be aware that there is a huge backlog of regulatory instruments that need to come forward to make changes to the regulatory system. I hope he will be able to give a great deal more priority to this issue over the next few months.
The noble Baroness, Lady McIntosh of Pickering, mentioned dispensing doctors. Noble Lords will perhaps not be unaware that there is sometimes a tension between community pharmacists and dispensing doctors, but that does not mean that dispensing doctors do not have a valuable role to play in future.
The noble Lord, Lord Grade, made important points about closures and funding. I do not know whether anyone really understands how community pharmacy is funded. It is certainly a very complex situation, which in four years as the Minister responsible I am not sure I ever quite discovered. The noble Lord raised a substantive point there.
I was glad to have support from the noble Baroness, Lady Brinton. She spoke well about the fact that community pharmacies had to step up because access in other parts of primary care has become so difficult. My noble friend Lady Wheeler made an important point about minor ailment services and savings that could accrue to the NHS if community pharmacy were used more.
I was grateful for the Minister’s response. He painted the picture that in actual terms you could say the health service has more staff, but he will know that respected think tanks and analysts have been saying for many years now that, because of the nature of healthcare and demographic changes, we have to run very much faster to meet the new demands. That is where the problem arises in community pharmacy. The Minister will not be surprised that, because of the long-term challenges, many noble Lords in this House regret that the Government did not accept this House’s recommendation that we have a proper long-term workforce strategy which is funded to try to forecast and deal with those issues.
On the substantive issue of community pharmacy, it faces many challenges. Many community pharmacy businesses are facing a viability situation. I do not think that the current contract the Minister talked about is really doing what it needs to. I am hopeful about the talks that he mentioned and potential agreement in the future, but at the moment I doubt that the Government are really going to come up with the goods. It is a tragedy because here is a profession and a sector which could do so much more at a time of huge pressure. It needs to be given the wherewithal to do it. I wish to test the opinion of the House.
Ayes 193, Noes 119.