Motion to Regret
That this House regrets that the National Health Service (Pharmaceutical and Local Pharmaceutical Services) (Amendment) Regulations 2017, in delaying the review of the regulations governing the provision of community pharmaceutical services, do not prevent the closure of community pharmacies resulting from the budget cuts in 2016–17 and 2017–18 and changes to the way the funding is distributed (SI 2017/709).
My Lords, I beg leave to move the Motion standing in my name on the Order Paper. I so do because I am very concerned at the reduction in community pharmacy funding, at the very time when we need this precious profession to take on ever more responsibilities. In opening this debate, I take the opportunity to pay tribute to Mr William Darling CBE, the youngest ever president of the Royal Pharmaceutical Society, who died earlier this year. I had the pleasure of working with Mr Darling over many years in the NHS; it was he who brought home to me the hugely valuable role that community pharmacies play in the UK. I, the profession and the public will be ever grateful to him for his immense services.
I should also say by way of introduction that the Secretary of State, under current statutory requirements, was expected to initiate a review of the pharmaceutical and local pharmaceutical services regulations 2013 by 31 August this year. He has not done so because, according to the Explanatory Memorandum, the Pharmaceutical Services Negotiating Committee sought to judicially review the Secretary of State’s decision on pharmaceutical spending and the department decided to await the outcome of the review. Let me say at once that I do not object to that at all or, therefore, to the order. What I object to is the way the department has dealt with the profession over the whole question of funding.
I find it remarkable that a Conservative Government are effectively undermining both patient choice and the role of SMEs in their approach. On patient choice, it was clearly stated by Ministers at a meeting of the All-Party Pharmacy Group last year that the intention was to reduce the number of community pharmacies in this country. Remarkably, the department feels that there is too much choice for patients in our high streets. In effect, the change to funding they are making is reducing the number of pharmacies. The judicial review ruled in the department’s favour, but nevertheless established the legal principle that it is the duty of the Secretary of State to always bear in mind health inequalities when making judgments. The problem in relation to community pharmacy cuts is that the department has not done so; nor does it deliver the more clinical and effective approach that it said it wanted in its letter to the PSNC back in December 2015.
Community pharmacies are the most accessible of all healthcare services. Last year, they had, on average, 137 visitors a day, gave 281 medical reviews and dispensed approximately 87,000 prescribed products. My concern is that the cutbacks or reforms will have a painful impact on thousands of people and therefore need to be thwarted as soon as possible. By reducing the contribution that community pharmacies can make, there is a risk of an increased burden on already pressed GPs and A&E departments.
I remind the Minister of a PricewaterhouseCoopers analysis commissioned by the PSNC in England in 2015. It estimated that community pharmacies contributed £3 billion in value to the NHS, its patients, the public sector and the wider economy. This included £1.1 billion in cash savings for the NHS, £600 million in benefits to patients and £242 million saved in avoided NHS treatment costs. It is rather short-sighted to undermine a profession that can give so much to patients and relieve some of the pressure on a system that, overall, is really suffering at the moment.
The majority of community pharmacies’ funding comes, of course, from the NHS and is used to fund their premises, staff and all other operating costs. My understanding is that this funding was reduced by 4% in 2016-17, with a further reduction in 2017-18, making a total 7.5% drop from 2015-16. Some pharmaceutical contractors claim that the payments to them have been cut by as much as 20%. We know that the Government have brought in some reforms—combining dispensing fees into one, a special funding scheme for pharmacies in isolated areas, a scheme for high-performing pharmacies and a pharmacy integration fund—and I welcome those payments. The problem is, they will not ameliorate the impending crisis faced overall by many community pharmacies.
One of the reasons given by the Government is that they think there are simply too many community pharmacies in some parts of the country. It often seems to me that the Department of Health lives in a world of isolation, ignoring general government policy. I had rather thought that the Government were in favour of consumer choice and therefore having more community pharmacy premises on the high street would be a good thing, not a bad thing. No doubt the Minister can enlighten me on the Government’s view on that matter.
One has to be clear that although Ministers have said they are worried about the number of community pharmacies, the reality is that those cuts will actually affect mainly the smaller pharmacies, which tend to be in the deprived areas. This is the real concern here. The fact is that there is financial instability in the sector. The reduction in NHS funding has led to pharmacies having to face worryingly high and unexpected wholesale bills if they want to maintain an adequate level of stock, which clearly they need to do. They face the potential prospect of banks withdrawing credit because income covenants have not been reached, due to the inability to find a source of credit to cover the aforementioned bills.
In a desperate attempt to keep the business viable, community pharmacies are reducing their services to patients. Because they are having to reduce their staff costs and make staff redundant, they are reducing opening hours and apparently cutting some free services, such as delivering prescriptions to the home, which particularly benefit older people and those with long-term degenerative conditions. We know that community pharmacies were under significant financial strain this summer. We are concerned that as we move into the winter, that financial strain will grow. Of course, it is mirrored by the pressure on the NHS at the moment.
Last year community pharmacies provided 950,000 flu vaccinations. There is a reason for this: it is very convenient. You do not have to wait until the surgery tells you that you can come in one Friday when it is able to give you a vaccination. You can go into a pharmacy and have it immediately. Already this year, community pharmacies have given out 500,000 flu vaccinations—a figure that could double by December. It is just one example of community pharmacies’ huge potential. They could do more—much more—if they were fully engaged in the kind of planning we need to see at local level.
Last night in your Lordships’ House we debated sustainability and transformation programmes. I do not think many STPs have mentioned the contribution that community pharmacies could make to providing services which, otherwise, other bits of the health service will have to. It is a pity because I believe this profession could provide much more support for the system and for patients in the future. I am worried about the impact of the financial reductions that have been made. I hope through this debate to at least encourage the Government to think again. I beg to move.
My Lords, I am happy to lend my support to this regret Motion. For many years, pharmacies have been the lynchpin of our health service. Before the NHS was formed, the pharmacist was the expert who those without means went to for advice and medicine. With the advent of the NHS and a free general practice service backed up by free prescriptions, the role of the pharmacist began to change. The last couple of decades have seen further change. Pharmacists began to reassert their role of offering advice to customers, being commissioned locally and nationally for public health and medicines support.
In 2015 the Government proposed 6% cuts to the pharmacy service and suggested the ways in which this might be achieved, including a reduction in the number of pharmacies and the adoption of internet supply. This was solely a budgeting exercise and lacked any evidence base or indeed impact assessment. The Chief Pharmaceutical Officer suggested that we have 3,000 too many pharmacies without offering supporting evidence.
Apart from the pharmacy being a place where we collect our prescriptions and buy over-the-counter painkillers and cough medicines, the public ask advice from the pharmacist on things they would not trouble a doctor with. Women access emergency hormonal contraception, while needle and syringe programmes are managed, as is the supervised consumption of medicines.
Pharmacies offer specific public health services, support with self-care and medicines support, including checking prescriptions and the New Medicine Service. In addition, they arrange deliveries of prescriptions to patients. That might be stopping in some parts of the country but in Cornwall it is ongoing. In 2015, there were nearly 12,000 community pharmacists dispensing a billion prescription items to the value of £9.3 billion. They are funded by both local and central government to provide essential, advanced and local services.
The PSNC was so concerned at the lack of evidence base for the Government’s decision that it commissioned PwC to look at 12 specific services and determine their net value. In 2015, more than 150 million interventions were made, along with 75 million minor ailment consultations and 74 million medicine support interventions. They also served more than 800,000 public health users, for example with supervised interventions and emergency hormonal contraception. PwC determined that patient benefits totalled £612 million, that the wider societal benefits were £575 million, and that the NHS benefits to the tune of £1,352 million. There are other benefits to the public sector of £452 million. That is a total just shy of £3 billion of benefit which, in one way or the other, comes to us all from having community pharmacists. That is just the financial benefit and does not include the benefit of Joe Bloggs or Mary-Jane being able to walk in and ask their pharmacist a quiet, discreet question and get support, help and advice.
I suggest that when not only our GPs but our A&E services are under immense pressure from patients presenting with conditions that do not require prescriptions or that level of advice, this is not the time to take away from the high street the welcome and expertise of the neighbourhood pharmacist. Will the Minister persuade his colleague to stop, look at the evidence and protect these services which are so vital to the communities they serve?
My Lords, in debating this regret Motion I listened intently to the noble Lord, Lord Hunt. He agrees that more pharmacies should be more engaged and that people should have more choice. I agree with him, but in today lies an opportunity to acknowledge the unique contribution that community pharmacists make to the health and care sector by providing easy access to clinical advice. I refer at this point to my entry as listed in the register of interests.
We should acknowledge that the Government are spending over £150 million a year more on pharmacies than the last Labour Government did, with over 11,500 community pharmacies—up by 18% over the last 10 years—together with the growth in the service budget of 40% over the last decade, to £2.8 billion in 2015-16. We now see over 40% of pharmacies in clusters of three or four, which means that in some cases two-fifths of pharmacists are within 10 minutes’ walk of two or more others. So it is right and proper that the Government are having this review to make absolutely sure that no community, whether in urban or rural settings, will be left without a pharmacy.
I want to pay tribute to the people who work in those pharmacies. In many cases, they are located at the heart of our communities with trusted professionals on-site who reflect the social and ethnic backgrounds of their residents. They are not only a valuable health asset but an important social asset, because they are often the only healthcare facility located in an area of deprivation and play a critical role in improving healthcare. Maintaining community pharmacies is crucial to keeping older and frail people independent. Going forward, we certainly do not want to see those people forced to travel, potentially over long distances, to pick up vital medicines and receive health advice. I very much hope that many rural communities, where travel distances can be a lot longer, can receive some sort of protection to ensure that patients can still access those services.
In 2017, it is right and proper to support a better payment structure and to be more efficient in the allocation of precious NHS resources—particularly by payment for the quality of service, not just for the volume of prescriptions dispensed—and to support the continuous improvement of those services to patients. That in turn will relieve pressure on many other parts of the NHS, particularly with a commitment to a national minor ailments service delivered through pharmacies so that patients who need urgent repeat-prescription medicines will be referred from NHS 111 directly to community pharmacies, rather than a GP out-of-hours service. We need to move from clusters of pharmacies to protect access for patients through a new pharmacy access scheme where there is a higher health need in a particular community.
The NHS has to be much more integrated. Pharmacists can make opportunistic public health interventions and provide advice on healthy lifestyles, thereby preventing or delaying the onset of long-term conditions and fulfilling a commitment to support people to keep healthy outside hospitals within the wider health system and a more integrated approach.
Finally, with the NHS asking for a £10 billion budget increase, there is an overriding need to see reforms to make sure that every pound spent goes as far as it can for patients and for the taxpayer as well. This package of reforms will ensure much greater use of community pharmacies as a first port of call by more fully integrating working with the rest of the NHS so that more people benefit from the skills of pharmacists and their teams. I am pleased that the Government are investing £112 million to deliver a further 1,500 pharmacists in general practice by 2020. I hope this review of the regulations, although delayed, will bring about the beginning of a longer-term transformation of the sector, expanding it to provide public health services such as health checks and immunisations as well as dispensing and selling medicines. There is no doubt that we all want to see a strong future for community pharmacy, but only if we can move with the times, because any delay brings uncertainty.
My Lords, I am fortunate to live in a lively Warwickshire village. There are two doctors with their own pharmacies, but every time I want something as simple as paracetamol I have to get the car out and drive eight miles to the nearest pharmacy. Last week, I was thrilled to see that the closed HSBC bank had a sign above it saying “pharmacy”.
I understand that in an NHS with increasing demands for funds it is not sensible to have pharmacies—each of which costs the NHS, on average, £220,000 a year—in abundance every few yards in urban areas. However, in rural areas it can be more than difficult to buy those essentials we rely on, especially if you do not have a car and there is an infrequent bus service. I congratulate the Government on being selective in supporting pharmacies that make life easier for country people while encouraging those small businesses to expand their basic service. In another village, I recently saw a sign in the window saying, “Opening hours: 6am to 9pm Monday to Saturday, and 9am to 5pm on Sunday”. What a service.
Last Saturday, I went inside the empty pharmacy and met Steve, the new pharmacist who is planning to open next week. He is enthusiastic to get going. So to him and all independent pharmacists who are free to flourish and to respond to the needs of the community, I say good luck, as they provide a really worthwhile service to the community. I am sure noble Lords will understand why I am not able to support this Motion.
My Lords, I declare an interest as chairman of the Climate Change Committee. I intervene only because one of the largest uses of vehicles is for health reasons. I hope my noble friend will not mind if I say that the Department of Health has perhaps not shown itself to be quite as central to the solution of our problems with climate change as other departments have. I hope this is going to change, and I am intending to bang on his door quite a lot until it does because this is a central issue.
This debate has shown that it is a useful one to have. I am not sure I want to enter into the party politics of it but there are quite good arguments about how many extra community pharmacies there have been, and there is certainly no doubt that the Government have shown themselves to understand this. No doubt there are other arguments, but the issue for me is proximity and propinquity. I am thinking not just about rural areas, although I live in a rural area and I understand the point very strongly; for many people in urban areas who do not have access to motor cars and where bus services are exiguous, the fact that they can walk to a pharmacy or ask others to do so if they themselves are unable to, is an important part of the kind of service that we need. It is disappointing that in the various collections of data we have not spent a bit more time looking at how many journeys are made and how many hours’ worth of diesel are used by people in accessing the health service. We know exactly how many journeys by lorry carry food—it is about 42% of all the lorry journeys in Britain—so we know a lot about these things, but I am not sure we know enough about what happens in the health service. When we are making these judgments, we have to make them in a holistic way.
So I do not apologise for the fact that on this, as on many other issues, I shall try to dramatise the fact that we should not be making decisions without asking ourselves, “What is the issue here in trying to meet the requirements which are now statutory?”. By 2050 we have by law to cut our emissions by 80%. We have to meet by law the fourth and fifth carbon budgets, and we have just issued the clean growth plan which is designed to deliver that end. There is nothing in any of that on the contribution of the NHS. It is time we asked the NHS to recognise that part of its role is to ensure that people’s access is as convenient as possible, not just for their convenience or because it saves money for other bits of the NHS, but because we as a community have to look at our statutory requirements to meet our climate change targets.
I hope that my noble friend will accept this as a preliminary thrust on the subject of the health service’s contribution to what we need to do. Indeed, in doing it, it is of course a circular system. Many of the problems the NHS has to deal with result from the subsidiary effects of pollution. It is not a matter not just of changing our climate but of the pollution at a much lower level physically but very high-level in terms of air pollution, and the damage that that does to health. I do not think this is something the health service can avoid and I hope my noble friend will take it into account.
My Lords, I should like to ask the Minister to clarify four issues. First, does he agree that community pharmacies are for many people the most accessible healthcare location, particularly where there are no GP surgeries locally; that community pharmacies in those situations can take pressure off GPs, and that in fact overall community pharmacies can take pressure off accident and emergency? Both GPs and A&E are experiencing rising demand.
Secondly, I am not clear whether the Government have responded to the Murray review and whether they plan to be clear what they think about that review, which was published in December last year. What policies do they have for community pharmacies as a consequence of that review?
Thirdly, we have heard about rural areas. I agree entirely with what has been said, but I shall talk in addition about deprived urban neighbourhoods where few people have cars. Has the department done an impact assessment on deprived communities’ access to health and care services, because I think it is material to this debate, particularly in the context of my fourth question? Do the Government accept that many pharmacies have cash flow problems? Many do, and I understand that it will be much worse from next month. What exactly is the Government’s grand plan? I cannot see one at the moment.
My Lords, I begin by thanking all noble Lords who have spoken in this interesting debate. Obviously, the Government disagree with the premise of the Motion of the noble Lord, Lord Hunt, but I am grateful for the opportunity that it has given us all to discuss this critical sector. I join the noble Lord in paying tribute to Bill Darling. I did not have the opportunity to know Mr Darling but, having researched his career, I can see that he was a man with a deep commitment to serving his community and the public, and showed true leadership throughout his life, so I pay tribute to him on behalf of the Government and send our condolences to his family and friends.
Perhaps no noble Lord has done more than the noble Baroness, Lady Jolly—I welcome her to her position on the Liberal Democrat Front Bench—to list the benefits and impact of the community pharmacy. It has a vital role to play in the nation’s health. More than that, pharmacies are, as my noble friend Lady Redfern pointed out, both a health asset and a social asset. They play more than just a straightforward health role. There are about 1.6 million visits to community pharmacies a day, and more than 11,500 community pharmacies are in operation, which is 20% more than in 2004-05.
As several noble Lords have pointed out, not least the noble Lord, Lord Shipley, they are increasingly important as healthcare moves into the community, and they certainly have a role to play, particularly in primary care, probably less so in A&E or urgent care. I reassure all noble Lords that the work of community pharmacies is deeply valued by the Government.
The regulations specify a detailed market entry and exit regime and terms of service for making arrangements for NHS pharmaceutical services in England. Their aim is to ensure that there is a proportionate regulatory framework which encourages the delivery of NHS pharmaceutical services that meet local needs, without excessive provision in areas already meeting demand. The regulations have been continually reviewed and updated since their inception, and the Government are committed to conducting a full post-implementation review. The regulations amend the deadline for that review, which was originally 31 August 2017.
As has been discussed, the delay is due to two reasons. First, the judicial review by the negotiating partner, the Pharmaceutical Services Negotiating Committee, was brought into the decisions made by the Secretary of State. We did not feel that it was appropriate to begin a judicial review, as the noble Lord, Lord Hunt, correctly said. Secondly, of course, we had a general election, and therefore a purdah period, followed by the summer holidays. That had some impact on the ability to conduct proper stakeholder engagement before the deadline. Therefore, the deadline was extended to 31 March 2018, to allow proper and wide-ranging engagement of stakeholders, so that we can fully consider whether the regulations are delivering their intended outcomes. A further stakeholder meeting is scheduled for later this month to present the emerging findings to these stakeholders and to shape the final report to be published early next year. I apologise if I have laboured the point about why the delay happened, but I thought it would be useful, given that it is the topic of the debate.
We have heard today concerns about the wider impact of the community pharmacy reforms, and the important services that pharmacies provide. It is worth setting out by way of background that the 2015 spending review reaffirmed the need for the NHS to find £22 billion in efficiency savings. Community pharmacy is a core provider of primary care and must play its part in helping the country eliminate the deficit that the previous Government left us. However, in designing the reforms we looked not only at allocating precious NHS funding more efficiently, but at improving services for patients and the public and better integrating community pharmacy into the wider health service.
As a consequence, included in the reforms are, first, a simplified payment process, moving away from payment arrangements that reward pharmacies solely for operating; and secondly, a pharmacy access scheme that protects access for patients in areas where there are fewer pharmacies, and in some cases takes account of higher health needs. That is precisely the kind of protection that my noble friend Lady Redfern called for in her very wise remarks. I am absolutely delighted that it is delivering a new pharmacy in the village of my noble friend Lady Seccombe. These pharmacies have been protected from the full effect of the funding reductions, so that patients can continue to access the services they need. I should point out that within the pharmacy access scheme, there is a review process, and one of the funding change criteria for reconsideration was whether that pharmacy was serving a deprived community. That answers one of the specific questions from the noble Lord, Lord Hunt, about the reforms.
Thirdly, the changes include quality payments which, for the first time, link payment to the quality of services pharmacies provide to the public, not just the volume of prescriptions they dispense. This should lead to improved patient experience, improved clinical effectiveness and increased integration, with over 90% of pharmacies now taking part in the scheme.
In parallel, the Government have introduced changes to relieve pressure on other parts of the NHS by embedding pharmacy in the urgent care pathway. Patients who need urgent repeat prescription medicines—coming to a point made by the noble Lord, Lord Shipley—are now referred from NHS 111 directly to community pharmacies, rather than via a GP out-of-hours service. Furthermore, we are piloting a scheme to increase the number of NHS 111 calls that can be fully dealt with by referral to a community pharmacist. Building on that, the Pharmacy Integration Fund is providing developmental training and exploring the use of pharmacists in GP surgeries, care homes and urgent care hubs. Many of those pharmacists have a community pharmacist background, and we are seeing better communication and integration of community pharmacy in patient care through these initiatives.
Several noble Lords have raised concerns about the closure of pharmacies resulting from the efficiency savings, but that was not the aim, and nor has it been the result. I can confirm that the number of pharmacies remains at or around pre-2016 levels and that there are more than 11,600 community pharmacies in England dispensing NHS prescriptions. As my noble friend Lady Redfern pointed out, it is an 18% increase in the last 10 years. Furthermore, 88% of the population remain within a 20-minute walk of a community pharmacy, which I hope will satisfy my noble friend Lord Deben on his question about the role that community pharmacies claim in reducing the environmental impact of the health service. He will be pleased to know that my honourable friend Claire Perry, the Minister in the business department who is leading the green growth strategy, has already nobbled me about the NHS’s role in this, so he is building on firm foundations, and I look forward to discussing those more with him.
There was one additional point on cash flow made by the noble Lord, Lord Shipley, that I would like to talk about. There is recognition of this, and the department is working with the trade body and pharmacies to look at this issue which results from some specific changes. I can reassure him about that, but I would be happy to talk more to him about it, or to introduce him to officials if that would help.
To conclude, I can reaffirm and reassure all noble Lords about the Government’s commitment to delivering a modern approach to community pharmacy—one that promotes efficiency and the best use of NHS resources while maintaining access to quality services and good patient outcomes. Pharmacy will continue to be a trusted partner in delivering a world-class National Health Service and the Government are committed to working with the sector to help make this a reality. On that basis, I hope that the noble Lord, Lord Hunt, will feel able to withdraw his Motion.
I am grateful to the Minister, and I echo the welcome given to the noble Baroness, Lady Jolly, in her position as Lib Dem spokesman on health. I thank the noble Baroness, Lady Walmsley, for her sterling work over the last couple of years—we very much enjoyed working with her, particularly when we combined to defeat the Government on a number of occasions. Long may that continue.
I very much welcome the response from the noble Lord, Lord O’Shaughnessy. The review is very important, and I hope we will have an opportunity to debate these important matters. I am not sure that he is really in a position to talk about the deficit any more. I would refer him, perhaps, to the comments of the former Chancellor, Mr Osborne, about who exactly was responsible for the financial situation that we as a Government found ourselves in. I shall not carry on in that mode, but I think the Government’s mantra needs perhaps to move on.
Efficiency savings are one thing, but cuts to community pharmacies are another. That is where we really disagree. On the issue of closures, Mr Alistair Burt went to the All-Party Pharmacy Group in 2015 when these proposals first came out and said that he thought that thousands of community pharmacies would close. There is no question that cash flow is a real worry. I am very interested in what the noble Lord said, and it would be good to know the outcome of those discussions, but I can tell him only that in the sector there was very real concern about this.
I come to SMEs. The risk is that it will be the very small multiple, individual community pharmacies that will be the most affected. I do not know whether the Minister knows, but in 2015 Matthew Hancock for the Government announced an ambitious target to get more small businesses working on central government contracts. The target was set that, by 2020, £1 in every £3 by government would be spent with SMEs. I guess that there is a question of definition here, of the extent to which that is regarded as a central government target or not. The point is that last week Mr Damian Green in the Cabinet Office announced that the target is being missed by a considerable margin and that it has gone from being a hard target for 2020 to an ambition for 2022.
What is happening here today is symptomatic of the Government’s approach to SMEs. They say that they are important, but the actions of individual government departments are to make it more difficult for them to do business. This is where I am concerned that the cumulative impact of these cuts will have a damaging effect on the small independents, which would be a great pity.
The noble Baroness, Lady Seccombe, said that she was fortunate to live in Warwickshire, and I endorse that—it is second only to God’s own city, of course. I was delighted to hear about the opening of a new community pharmacy in the premises of a bank. That is good, and I welcome the four schemes to which the noble Lord referred. I have no objection whatever to that, but the problem is that overall the package of proposals reducing the funding will put many community pharmacies at risk; they will often be in vulnerable areas and will reduce patient choice. The point that I put to him is that I do not think we are making as much use of community pharmacies as we could.
The 2012 changes took many community pharmacies away from the table. With PCTs, they were more around the table. CCGs at first did not have the responsibility for community pharmacy contracts, although I think they have more influence now. But we have to be realistic: GPs are not always as supportive of community pharmacies taking on more work as one would wish them to be. Some of that is about finance, and where it goes. Alongside the issue of funding, which I hope will be reviewed, I hope the Government will see how we can ensure at a local level that community pharmacies are heard more, have more influence and contribute much more, because I believe they have the professional skills to do so.
Finally, it was a great pleasure to hear the noble Lord, Lord Deben, talk about the impact of this measure on the environment and climate change. We sometimes forget that the desire of the NHS to centralise many of its services can lead to more car miles. I hope we will take that factor into account in the future.
This has been a very good debate. One thing on which we are all united is the role of community pharmacies, which is a very good thing indeed. I beg leave to withdraw my Motion.