APPENDICES TO THE MINUTES OF EVIDENCE
APPENDIX 1
Memorandum by The Patients Association
(PS1)
The recommendations contained in the OFT's recent
report "The control of entry regulations and retail pharmacy
services in the UK" would allow any licensed pharmacy to
claim NHS dispensing fees as of right. It would do this by eliminating
controls on the number and location of community pharmacies contracted
to supply NHS pharmaceutical services. The latter were introduced
in the 1980s to promote a better planned distribution of pharmacies,
and encourage investments in premises and service improvements.
The OFTs' suggestions are intended to defend
the public's interests by promoting greater competition in the
supply of over the counter and prescription medicines, and the
delivery of associated services. The Patients Association respects
the integrity of the OFT. It also accepts that more patient choice
and greater consumer empowerment in health care is vital, and
that this can often best be pursued by removing needless restrictions
on access to goods and services. (For example, The Patients Association
is broadly in favour of the concept of direct to consumer advertising
of all medicines and free public access to medicines information
from any source, providing that regulatory systems are in place
to ensure information accuracy and prevent attempts to mislead
or exploit the public.)
However, The Patients Association notes that
community pharmacy is already far more competitive and market
oriented than other parts of the NHS. It fears that the Office
of Fair Trading failed to consider community pharmacy as an integral
part of the health service, which is in need of further modernisation
and improvement. The Patients Association believes that pharmacy
needs to be developed as a health care and public health improvement
resource, rather than as a privatised vehicle for supplying prescribed
products and retailing over the counter (OTC) medicines as cheaply
as possible.
The patients and other NHS service users who
most need a well planned, well distributed community pharmacy
network are the often relatively poor, frequently less physically
able, typically older individuals who need regular medication,
and those who care for them. The Patients Association is also
concerned about service users such as drug abusers, who may need
services such as supervised methadone provision and needle exchange
facilities. The members of such vulnerable groups tend not to
be people who have easy access to shopping centres and super markets.
It is the relatively healthy, relatively wealthy, who are most
likely to benefit from a more "free market" approach
to pharmaceutical or other forms of health care provision.
PHARMACEUTICAL CARE
QUALITY
The OFT considered the quality of pharmaceutical
care in relatively superficial terms. For example, issues such
as the need to limit the volume purchase and consumption of pain
killers and other classes of medicine in order to protect the
public's health do not seem to have been properly factored in
to its calculations. Lowering the unit costs of medicine sales
may well undermine the ability of community pharmacists to protect
the public's health in this manner, even—or perhaps especially—in
"high foot fall" (that is, busy) super market and allied
settings. Improving the appropriate access of relatively poor
people to over the counter medicines is more likely to depend
on the NHS' ability to plan and fund minor illness treatment initiatives
in locally sited community pharmacies than it is to stem from
ending the health service's ability to stop new NHS contractors
opening in locations which are already well served.
In addition, the OFT report does not from the
Patients Association's perspective appear to view problems such
as community pharmacy "leapfrogging" which occurred
in the 1980s with sufficient gravity, both with regard to their
impact on pharmacy premises investment levels and the implications
for the future balance between general medical and pharmaceutical
service access points. ("Leapfrogging" involved pharmacies
repeatedly changing locations in order to move closer to GP surgeries,
and was one of the main reasons for today's regulations.) Were
total de-regulation to be permitted, this could in current conditions
lead to unchecked GP practice/new pharmacy mergers which—baring
significantly increased NHS investment in supporting universally
accessible pharmaceutical care—could radically undermine
the existing community pharmacy service network.
The PA further believes that the OFT may not
have fully identified the harm to the overall public service that
dilution of the existing funding pool for NHS community pharmacy
could cause, were 1,000 to 1,500 more large store based pharmacies
be able to demand NHS fees "as of right". Even if the
presence of more pharmacies in busy locations would not in itself
undermine the financial position of smaller "local"
pharmacies as much as bodies representing community pharmacy may
presently fear, they could drive up the cost of pharmacy labour.
The latter is already in short supply. Increased
staff costs could drive a significant number of small pharmacies
to closure, unless additional public money is used to protect
them. At the same time it seems improbable that existing larger
pharmacies will be able to fund pharmaceutical care improvements
from their resources, were their individual shares of current
NHS pharmacy service funding to be significantly reduced.
IMPACT ON
UK PRIMARY CARE
DEVELOPMENT
"The control of entry regulations and retail
pharmacy services in the UK" does not analyse the impact
of its recommendations in the context of the DoH's Pharmacy in
the Future programme and its equivalents in Wales, Scotland and
Northern Ireland, or the implementation of the new GP contract.
As indicated above, it also neglects to consider the extent to
which pharmacy integration with general medical practice would
be precipitated by the proposed deregulation, and the effect this
would have on UK primary care development. Given that the new
GP contract currently being negotiated is likely to create new
incentives for the formation of larger practices and (in conjunction
with other NHS schemes) primary care centres employing pharmacists
and a range of other staff, this will also present fresh challenges
for both independent local and larger "chain" high street
pharmacies.
Finally, the Patients Association considers
the international comparisons contained in the OFT report to be
potentially misleading as far as the identification of the UK
public's interests in the future of community pharmacy is concerned.
There is a danger that they could obscure the fact that Britain
is already a pharmacy policy outlier within the European Union.
Most other EU nations have considerably more regulations than
does the UK in place to protect the professional integrity and
financial viability of community pharmacies.
Norway was for several reasons an unusual country
to have selected as a potential guide to British policy, not least
because of it geographical size and small population. Further,
differences between the US health care system and the principles
upon which the NHS is founded are so great that the relevance
of that country's approach to community pharmacy regulation (which
has had debatable results in terms of health service quality)
is similarly doubtful. The drawbacks of alternatives such as the
Dutch system (in which separate drug stores provide OTC medicines
in an arguably unsatisfactory way, and there are de facto strong
professionally imposed controls over pharmacy location and ownership
patterns) are not in the PA's view adequately taken into account
in the OFT's analysis.
CONCLUSIONS AND
RECOMMENDATIONS
The Patients Association believes that although
Government should welcome the OFT's contribution as well intended,
it should accept clearly that in health service development terms
it leaves many questions unanswered. The OFT's recommendations
on competition should be taken into account during the negotiations
on establishing a new community pharmacy contract already underway.
But in all parts of the UK Government should not take hasty decisions
about removing current controls on the number and locations of
NHS pharmaceutical service contractors before the terms of service
of the latter have been reviewed in full in relation to the overall
needs of the population.
In this context the Patients Association also
warns that in its view current funding provisions for community
pharmacy innovations aimed at improving the quality of NHS care
and medicines management for people such as those with minor and
chronic illnesses are inadequate, and unduly fragmented. The new
GP contract's terms are likely to increase GP practice public
funding by around 30 per cent in the next three to four years.
The Patients Association believes that similar funding increases
are needed in other areas of primary care, of which community
pharmacy is a key element. Moves aimed at reducing NHS authorities'
powers to influence the location of community pharmacies (and
which will further change the structure of pharmacy ownership
away from professionally owned or directed organisations) should
not be permitted to obscure this fact.
The Patients Association also strongly recommends
that changes in the regulation and funding of community pharmacy
should involve a full, honest, public debate about the types of
services people with health problems and related needs (such as
health protection) require and prefer. The Patients Association
has reviewed carefully the research undertaken on behalf of the
OFT into consumer use of pharmacies supplying prescription medicines,
and has found that despite being of good quality it did not adequately
address a wide range of issues relating to the future development
of NHS primary care services. Responsible policy makers should
not consider the OFT's investigation to be a satisfactory substitute
for informed, open, public discussion about how new incentives
might restructure community pharmacy in relation to the wider
NHS primary care system, and how members of the British most want
their future personal, medical and pharmaceutical services to
be delivered.
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