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Community Pharmacies

Volume 561: debated on Monday 15 April 2013

Motion made, and Question proposed, That this House do now adjourn.—(Anne Milton.)

Perhaps after waiting a moment for a suitably attentive and perhaps even respectful audience, the hon. Member for Ealing North (Stephen Pound) can rise from his seat to offer the House the benefit of his eloquence.

: I am extremely grateful, Mr Speaker, for your generosity and for the way in which you slowed down through the gears. It is greatly appreciated. I am strangely gratified to see such a well attended House tonight, and delighted on behalf of both myself and the Minister that all our colleagues will be staying here rather than miss a word of this Adjournment debate.

There are many reasons why a humble, insignificant Back Bencher should raise an item on the Adjournment. One can seek the ventilation of an issue; one can seek the investigation of an issue. One can seek adumbration or agitation, and possibly even instigation. In my case, it is with some trepidation that I approach a subject that is originally to do with celebration, but that then moves into the dark world of prognostication and, in the case of the Minister, implication.

There has been a quiet but dramatic and extraordinary revolution in the world of the community pharmacist. The traditional model of the dispensing chemist is as outdated as the mediaeval apothecary. I urge all right hon. and hon. Members to visit the new world of the community pharmacist, which will exist in their constituencies as surely as it does in mine.

It would be invidious to mention individuals in the context of the miracle that is occurring in north-west London, but if I were so tempted, the names of Nilesh Morjaria of the Church pharmacy, of Mahendra Gokani of Mandeville road and of C.K. Nathwani of the Ravenor pharmacy would feature strongly, as would Usha and Dilip Shah of the Alpha pharmacy in Northolt. It was at a visit to that estimable emporium, kindly facilitated by the Royal Pharmaceutical Society in the person of the passionate Charles Willis, once an ornament of this House, that the full range of services now available from what we once called our “local chemist” became apparent.

The Minister will be well aware that the core role of the pharmacist—the dispensing of medicines—has grown from 556 million medicines in 2002 to 885 million medicines in 2011, an increase of 56%. I will return to the current figures. The patient or the customer will find the community pharmacist offering services such as home delivery of medicines and medicines use reviews, which ensure that patients gain optimal use from prescribed medicines—2.4 million people took advantage of such a review in the last year and the outcomes were staggering. Forty per cent. of asthma sufferers showed better asthma management and 55% of patients with chronic obstructive pulmonary disease demonstrated a reduction in symptoms following a medicines use review.

The consequential reduction in emergency visits to accident and emergency departments will bring a warm glow to the Minister’s heart and to the hearts of his Treasury colleagues, as will the new medicine service, which advises patients on the therapeutic use of newly prescribed medicines. Evidence already exists that shows that 31% of those who make use of this new medicines service adhere more fully to prescribed medicines, minimising waste and increasing their effectiveness.

Smoking cessation is one of the supreme achievements of the community pharmacists in my part of the world, and Usha and Dilip Shah have not only improved quality of life by their efforts, but actually saved lives, as theirs is one of the most successful smoking cessation services offered. As one who had his last gasper in February 2006, I can speak of the effectiveness of this service from a position of breathless authority.

There are more than 20 different services cited by the health and social care information centre, including the monitoring of anti-coagulant medicines, minor ailment schemes and supplementary prescribing services, but countless additional services are available, from flu vaccine provision to travel clinics. In the case of C.K. Nathwani, the Ravenor pharmacist, a mobility clinic supplies wheelchairs and dispenses walking frames and commodes, all in a friendly and familiar environment close to the patients’ homes and with no queuing up.

I recognise that the hon. Gentleman is saying that pharmacists do an incredibly good job, and I agree, but does he agree that we should seek to decriminalise any dispensing errors that pharmacists might make? They can go to prison for such errors, but GPs are merely struck off.

Not for the first time, the hon. Gentleman raises an extraordinarily interesting point. I will discuss later the issue of the level playing field for pharmacists. Far be it from me to suggest that he might wish to seek his own Adjournment debate on that subject as it is one of great significance, but I do not disagree with the points that he makes. I look to the Minister for a similar statement.

The Minister will conclude that I have certainly ventilated the approbation and celebration I referred to earlier, but all is not well—all is not sweetness and light in the well-lit and warm world of the community pharmacy. I hope that the Minister and I can agree that the community pharmacist is the third pillar of the NHS and, just as general practice and hospital care defined the early days of the NHS and were labelled as the two great pillars on which the new creation stood, the changing role of the community pharmacist can come to define a third pillar.

The cruel tyranny of time prevents me from fully detailing this proposition, but I refer the Minister and the House to the excellent 2013 UCL school of pharmacy lecture “From making medicines to optimising health”, given by the chief executive of the Pharmaceutical Services Negotiating Committee, Sue Sharpe. Dr Sharpe identifies the intentions of the 2008 White Paper “Pharmacy in England”, while rightly deducing that even in the short time since then the nature of the community pharmacist has changed over and over again. She should also be credited with allowing me to remind the House of the marvellous quote from Auden to which she refers in her lecture:

“Health is the state about which medicine has nothing to say”.

At one level, the picture is one of rosy growth and rude good health. Diversification in over the counter sales has increased the profitability of the pharmacist, and a new form of health care and preventive medicine has emerged almost without notice and certainly without fanfare. The NHS is so effusively documented at every level that I am sure I could find the evidence of my birth in the first week of the NHS in Hammersmith in July 1948, when I was one of the first of what Aneurin Bevan identified as “bundles for Britain’s future”—I like to think that he looked down on me swinging in my white-painted metal bassinet in Queen Charlotte’s hospital and identified me as a class warrior of the future, although I would sadly disappoint him in that area. The fact that I am still alive, however, is a credit to the NHS. In such a system, it is extraordinary that there is a real paucity of documentation relating to the range of services and extent of outcomes of community pharmacy. Hopefully, this will not remain uncorrected, but I freely admit to my concerns about the place of the community pharmacist in the new NHS structures. I very much hope that the Minister will allow me to share these concerns with him tonight, and also allow me to look in gentle supplication to him for some positive suggestions.

The Minister is all too well aware that the Health and Social Care Act 2012 empowers clinical commissioning groups, led by GPs, and health and wellbeing boards to play the key role in shaping local health care services. I contend that commissioning public services on a localised basis may lead to variations in availability, quality and outcomes. I realise that we have discussed this at length, and I do not want to rehash the arguments that wracked the House during the passage of the Health and Social Care Act 2012, but one way in which this apparent deficit could be addressed is through pharmacy representation. There is currently no pharmacy representation on health and wellbeing boards. Such representation could be a catalyst for constructive change in primary care. Even the pharmaceutical needs assessments drawn up by the health and wellbeing boards may lack any input from pharmacists.

The sheer complexity of the arrangements under which the new commissioning arrangements operate can be a barrier to the provision of services. I am indebted to Benjamin Wheatley of Boots for confirmation that individual contracts now require pharmacy contractors to invoice either local authorities or clinical commissioning groups via the NHS shared business services. I have to say that my head aches when I try to contemplate the mechanism whereby one invoices through all these various groups and all the choices concerned. I am all in favour of choice, but sometimes it is ridiculous. In cases such as this, we are actually preventing good people from doing good work. The effect of this additional work load can be catastrophic.

I do not often praise, without reservation, coalition Ministers, with the obvious exception of the hon. Gentleman who adorns the Dispatch Box this evening, but I pray in evidence the words of the noble Lord the Earl Howe, speaking at the pharmacy business awards dinner in 2011—what a night that was—when he said:

“The Government sees pharmacy as integral to every aspect of our plans to modernise the NHS.”

He went on to say:

“there is still some way to go before our reforms are in place. This transition period is an opportunity for pharmacy to make its presence felt.”

I profoundly hope that the transition period does not follow distant historical, if not to say Trotskyist, precedent and aspire to a state of permanent revolution. I sincerely hope that the Government can allow the community pharmacists to do what they do best.

At the present time the playing field is not level, but opportunities there are aplenty. One of the five domains in the NHS outcomes framework—I have to say, Mr Speaker, that the Minister is a good and decent and honourable man, and I have had the pleasure of his company and his acquaintance for many years. I cannot believe that he would ever talk about the “five domains of the NHS outcomes framework.” There are those around us who do and it is to them that we must give credit tonight, but let them come out with this peculiar, strangulated syntax. I hope that the Minister will reply in honest, Norfolk talk.

The NHS outcomes framework refers directly to the quality of life for people with long-term conditions, and this is an excellent opportunity for the community pharmacy, in addition to other qualified health care practitioners, to deliver a key aspect of the Government’s new health care system in England. The pharmacist, as is so obvious when one comes to think of it, may often be the first person to spot a development in a patient’s condition. An early identification can be therapeutically priceless. It is often the community pharmacist who notes that someone has not come in for their medication or, when they are delivering to their home, that the person does not open the door, is looking more tired and pale, or occasionally has something more dramatic such as a nosebleed. This early identification is absolutely priceless, and this is where the role of the community pharmacist has changed beyond almost all recognition. I am seriously worried that such best practice, as recommended by Earl Howe, is threatened by the impact of changing priorities as commissioners change.

The funding passed to CCGs and local authorities is already being used to commission services from community pharmacies, so that for every new service there is a very real possibility that an existing one will be ended. Local authorities will, quite rightly, look to address their own priorities. I referred earlier to the additional pharmacy-led services in England and the huge growth in recent years, but 2012 actually saw a decrease of 5%. It is reasonable to assume that the transition period between commissioners in 2013 and 2014 will see that decline continue. It must be recorded that any diversion from existing services will have an immediate effect on patients. If there is one thing we can all agree on, it is how the community pharmacist has earned the trust of patients and the patient community. It has been so remarkable and beneficial that it cannot be threatened. If there is one thing that patients in long-term care plans in particular are terrified of, it is a change in the structure that could affect their medication and the ability of a community pharmacist to provide for their needs.

The General Pharmaceutical Council is the regulator of pharmacists, and as such pharmacists are not required to register with Monitor or even the Care Quality Commission. This lack of a registration number actually inhibits many pharmacists from applying to provide services under the “any qualified provider” scheme. I do not know why, but they cannot register. I have tried myself to operate the system for registering online. If someone wishes to provide a service, they have to give their registration number, and if they are not entitled to be allocated a number, the whole process stops. I hope that this small but significant and far-reaching improvement is one that, yet again, can be laid at the Minister’s feet, with the gratitude of the people, and that we can be delighted by another Lamb amendment.

Allied with the codification of a requirement for community pharmacist representation within NHS England and the resuscitation of the roles previously identified in SHAs and PCTs, a new model of integrated health care could relieve pressure on general practice, provide local and accessible services, manage long-term conditions and deliver healthy living advice. In my part of the world, we have a huge number of singlehanded GP practices. They are typically elderly men—occasionally women, but usually men—operating in terraced houses. It is most unlikely that they can be sacked—I am not altogether sure they should be sacked—but they need a complementary service, because the singlehanded GP model is simply not appropriate to the dizzying variety of illnesses and conditions that apply particularly in the urban environment at this the beginning of the 21st century. I would like to see a synergy between community pharmacists and general practitioners working together to the benefit of all patients.

Above all, pharmacies can work with the new health bodies, GPs and other health care professions to support a modernised, caring health care system that delivers high standards of patient care. The Minister blanched earlier when I referred to him as a good and decent man. I meant that sincerely. I think that everyone in the House holds the Minister in the same esteem. He is a good and decent man, and I hope that he will consider some, if not all, of the points I have raised tonight and agree with me that a fair following wind from the Government would be greeted with delight and relief by our greatly valued community pharmacists and would go a long way towards ensuring a happy, hale and hearty nation and safeguarding our future.

I have received three messages from parliamentary colleagues inquiring whether this debate is a tribute to that distinguished former chemist, the late Baroness Thatcher. She achieved a great deal in the world of chemistry, and certainly as a woman she was an extraordinary achiever, but community pharmacists perform great miracles every day. Let us hope that the Minister is as convinced of their good will and good work as I am and that tonight he will put his shoulder to that wheel and advance the cause of integrated health care and the role of the community pharmacist.

I congratulate the hon. Member for Ealing North (Stephen Pound) not only on securing this debate on community pharmacies, but on entertaining us. At the end of a long day, it has been appreciated by the gathering before me, small though it might be. I can assure him that I am not often found talking about domains and the outcomes framework. He and I are at one on that. He talked about the quiet revolution he has witnessed in his constituency and the several fine pharmacies there. They do incredibly valuable work, and I can assure him absolutely that I see a critical role for community pharmacies. He talked about integrated care. They can play a central role in an integrated service for patients, particularly those with the long-term, chronic conditions he referred to, so I am completely at one with him on that.

Today, more NHS community pharmacies than ever offer health care treatment and healthy lifestyle advice and support in England. As I think the hon. Gentleman said, they dispensed 885 million prescription items last year—up 56% from 10 years ago, with nine in every 10 items prescribed. Pharmacies are also involving accessible. Research has shown that 99% of people can get to a pharmacy with relative ease, especially in more deprived communities, perhaps including parts of his constituency. Because of that, many people use their local pharmacy team as the first port of call for all sorts of health problems, both minor and major. Indeed, that might be the first point at which a serious condition is identified. For that reason, pharmacies are incredibly important. For example, many pharmacies now offer services that help patients to get the best from their medicines or provide support for patients with long-term conditions such as asthma who are starting a new medicine.

However, this goes beyond mere statistics. A graph or chart cannot represent the relief of an elderly person who gets help with a niggling cold or cough, the comfort that a pharmacist can provide a young mother worried about her child’s health or the benefits that people with diabetes or heart disease get from good lifestyle advice. This is all because people trust the community pharmacist. That trust is a vital commodity that should be very much valued. As the hon. Gentleman said, community pharmacies help people to live healthier day-to-day lives. I know he saw that for himself when he visited a pharmacy in his constituency recently. Indeed, I visited a pharmacy in my constituency in Sheringham recently. For a photo opportunity, I had a blood pressure test done on my arm. It came out that I had high blood pressure, so I was immediately referred to my GP. It happens that my blood pressure is all right, but that kind of reminder or shock to the system—in this case experienced by me—is of enormous value to many people, and he was right to highlight that.

The pharmacy that the hon. Gentleman visited has, like many others, helped thousands of people to quit smoking. He talked about his own experience. I am not sure whether he got help from a pharmacy, but I remember as his next-door neighbour over in Norman Shaw North that he used to smoke like a chimney and he has now stopped. That is an admirable achievement. Nearly three quarters of all pharmacies in England gave out quit kits last year, many as part of the Stoptober campaign, which was an enormous success.

Our pharmacies show how they can be proactive, not reactive places, genuinely improving people’s health and well-being on a daily basis, so I welcome the endorsement that the hon. Gentleman gave to the pharmacy’s history of good service. Demand for health care will increase. An increasing population, with people living longer and needing more treatment, means that we must harness every available resource to meet those needs. We want to see pharmacy’s contribution flourish in the future, very much as a central part of local health provision.

Only a fortnight ago, far-reaching changes to transform commissioning health care in England came into effect. Clinicians, not managers, are now in the driving seat. The NHS Commissioning Board—now NHS England—has responsibility for commissioning all NHS primary care services, including pharmaceutical services. We expect NHS England to involve clinical commissioning groups where appropriate, because they know the needs of their local populations best. To meet those needs, CCGs are free to commission further services over and above what NHS England commissions. If they want to, and if it is appropriate, CCGs can commission those services from pharmacies. Local authorities now have the powers and funding to commission public health services, such as stopping smoking or sexual health services, and are free to commission from pharmacies. That provides an enormous opportunity to pharmacies. There is an increase in the public health budget this year and next. It is important for pharmacies to get stuck in and make their case to local authorities about the service they can provide—accessible to all, on the high street and trusted, as we have agreed.

These are far-reaching and necessary developments. It is therefore important that new commissioners are fully aware of pharmacy’s potential. That is why the pharmacy and public health forum, chaired by Professor Richard Parish, has been working on how pharmacy can best enhance its role in public health, with more research into pharmacy’s contribution.

Our goal is to allow the new commissioning arrangements to make people healthier. The hon. Gentleman referred to integrated care, which I also mentioned earlier. The Government intend to focus on trying to achieve an integrated care model across the country, moving away from the fragmented nature of health care delivery towards a much more integrated model, and pharmacies can play an absolutely central role in that approach. Pharmacy has an excellent reputation when it comes to integration. I know that pharmacies have a track record of providing quality services that people value, and that patients and consumers hold pharmacy in high regard, so all commissioners should recognise the potential of community pharmacies. It is also clear that the relationship should work the other way, too. Just as commissioners support pharmacies, pharmacies should also be ready to support commissioners by making available their professional experience and specialist clinical expertise. Pharmacies should make the case to commissioners as to why they should consider the role of community pharmacies.

The hon. Gentleman referred to community pharmacy’s concerns about the new commissioning arrangements, and I hope that I can address some of those concerns and reassure him. The first big concern involves the availability of senior pharmacy expertise and pharmacy’s role in commissioning. I want to assure the hon. Gentleman that the chief pharmaceutical officer for England is already part of the senior management team at NHS England. NHS England is looking at how its regional and area teams can make use of appropriate pharmaceutical advice.

The hon. Gentleman also pointed out that some pharmacists are concerned that they are not represented on CCGs. We deliberately did not prescribe set lists of other health professionals who should be on CCGs’ governing bodies. CCGs must be free to decide that for themselves, because it is they, not us, who know exactly what is suitable for their communities. If every single profession were represented on every single board, that would make for bloated and top-heavy organisations, which is exactly the opposite of what we want to achieve. However, CCGs have a duty to get advice from a broad range of health experts. CCGs can involve pharmacy, and I would expect that involvement to be commonplace, given the extent to which pharmacies are involved in people’s care. I am sure that the existing local pharmaceutical committees and the new local pharmacy networks will be more than willing to offer advice and support to commissioners. I hope that they will do so, and that they will make the case to the commissioners that they can improve care.

The second big concern involves the potential for pharmacy-led care to stop. I understand that concern—it is natural at a time of transition and significant change—but I do not share the apprehension. I see a potentially greater role for pharmacies, if they can make their case effectively. NHS England is legally required to commission pharmaceutical services that meet health care needs. It bases that on the assessments of pharmaceutical needs for which the health and wellbeing boards are now responsible. As I said, pharmacy’s reputation is well established. Commissioners are not going to stop effective and proven pharmacy services overnight. I can reassure the hon. Gentleman that, as CCGs have no power under the Health and Social Care Act 2012 to commission pharmaceutical services, they cannot cut or decommission those services either.

Will some things change? Yes, of course they will. We would not have embarked on our reforms of the NHS if there had been no need for change. For example, local authorities have already taken over responsibility for public health services such as smoking cessation services. Pharmacy absolutely has its place in the new NHS. Not only that, but in my view it must surely grow to meet the increasing needs of our communities. The reformed commissioning environment provides new opportunities for pharmacies. If they remain passive and do not seek to make their case, they will suffer, but if they go out and make the case for the central role that they can play, for their accessibility and for the trust that the community has in them, they will be able to thrive and prosper, particularly given the focus on a new integrated care model. They can demonstrate how they can improve health and improve people’s well-being.

The third big concern is that CCGs’ commissioning decisions will be unduly influenced by people with a vested interest in securing contracts and cutting pharmacies out of the equation. The Department’s view is that this is unlikely to happen. The idea that members of CCGs will secure all the profitable and lucrative services for themselves is a pretty negative view, and one that I do not share, but of course we have to be vigilant.

We will not allow a situation to develop where profits come before patient care or patient choice. That would be in direct contradiction of the founding principles of the NHS, and it must not happen. We have put robust governance arrangements in place and guidance was issued last year to all CCGs. Registers of interests must be maintained and available for public scrutiny. Members and employees must declare any conflict or potential conflict in relation to a decision to be made by the group, and there are effective sanctions if those principles are breached. In addition, the General Medical Council published updated guidance for doctors last month. It comes into effect a week from today, on 22 April. It includes a section on doctors’ financial and commercial arrangements and conflicts of interest. The GMC has provided supplementary guidance explaining how doctors can put those principles into practice.

I conclude by thanking the hon. Gentleman once again for the opportunity to discuss the crucial role of community pharmacies in the new health and care system. The new arrangements will allow commissioners and pharmacists to work closer together, not in opposition. There will be new opportunities for better and more flexible pharmaceutical care arrangements that are both relevant and accessible to local people. Underpinning these will be effective governance—

House adjourned without Question put (Standing Order No. 9(7)).