158.Community pharmacists are independent contractors responsible for the processing and dispensing of prescription and over the counter medicines. In addition to their dispensing function community pharmacists also provide a range of patient-centred services and take part in public health promotion campaigns.
159.A recent survey found that an estimated 15 million informal interventions take place in community pharmacies across Northern Ireland each year, of which 4.4 million (almost 30 per cent) were likely to have prevented harm to patients. An estimated 850,000 cases of potential patient harm are prevented annually through medicines optimisation interventions by community pharmacists. Over 2.5 million interventions for minor ailments or over the counter advice and support are provided in community pharmacies each year, with 700,000 provided to children. Over 360,000 referrals to health and social care professionals are made by community pharmacists annually. The majority of these are to General Practice, though an estimated 80,000 are made to out-of-hours centres and emergency departments, with a further 30,000 signposted to community and voluntary support centres.
160.Community pharmacists also make a wide range of public health-related interventions each year. These include:
161.In addition to these informal interventions, community pharmacies in Northern Ireland run a range of services formally commissioned by the HSC. Each year, the average Northern Ireland pharmacy:
162.There are currently 532 community pharmacies in Northern Ireland, including in some of the most rural and deprived areas. This equates to 28.4 pharmacies per 100,000 of the population. By comparison, England has 20.9 per 100,000, Scotland has 22.9 and Wales has 23.2. In excess of 99 per cent of the population in Northern Ireland live within five miles of a pharmacy, with 80 per cent of the population living within three miles. It has been estimated that approximately 123,000 people visit a pharmacy each day in Northern Ireland and satisfaction levels with community pharmacy are high—according to a recent survey 98 per cent were reported to be “satisfied” with the services provided by community pharmacy and 66 per cent were “very satisfied.” Very few differences in these levels were reported between different demographics or HSC Trust areas.
163.The average monthly dispensing volume per pharmacy has increased from 5,071 items in 2008–2009 to 6,512 items in 2018–19 with £423.3 million spent on prescriptions in 2018–19. The average prescribing cost per person increases with age and older males tend to have a higher prescribing cost than females. A male of 85+ will typically have a prescribing cost twelve times that of a female aged 5–14. In 2018–19, 32 per cent of the total cost of prescriptions was attributed to the 45–64 age group. With increases in life expectancy and major demographic shifts as the population ages these numbers are projected to further increase.
Figure 6: Prescribing cost by age and gender, 2018–19
164.Northern Ireland has the second highest number of items prescribed per head of population after Wales (though this may partially be explained by Welsh prescribing intervals being shorter than elsewhere in the United Kingdom) at 22.4 per head of population in 2018. This compares with 19.9 in England and 19.1 in Scotland. However, we heard that these figures may not capture the full extent of dispensing in Northern Ireland—Community Pharmacy NI told the Committee that:
While these [figures] confirm a higher level of dispensing in Northern Ireland, the extent is under-reported as it focuses only on ordinary dispensing, excluding multiple dispensing figures. Multiple dispensing accounts for over 13 million dispensing episodes per year in Northern Ireland but this activity is not included when figures are compared to other parts of the UK, despite it being factored into other UK dispensing figures, generally as seven-day prescriptions.
Furthermore, for the last five years Northern Ireland has had the highest net ingredient cost per head of population in the United Kingdom—in 2018 it was £226.32 per head, 43 per cent higher than in England.
165.In January 2017, prior to the collapse of the Executive, the Health Minister signed a Memorandum of Understanding between the Department of Health, Health and Social Care Board and Community Pharmacy NI to engage in negotiations aimed at developing a new framework for community pharmacy services by 31 March 2017. However, the Committee heard that though the framework has been agreed, funding negotiations had stalled.
166.The Committee heard that community pharmacy in Northern Ireland was facing a “severe funding crisis” that was “unprecedented” and “threatening the viability of pharmacies across Northern Ireland.” This had largely been due to extrapolation of the English Drug Tariff which does not take into account Northern Ireland’s higher levels of community pharmacy workload or medicine procurement per head of population. We were told that this was the “fundamental problem” with community pharmacy funding arrangements. We were told that extrapolations have instead been carried out at a crude population level and omit funding provided to dispensing doctors in England, resulting in a distortion of baseline figures. This had led to underfunding of at least £60 million since 2011.
167.We heard that many community pharmacists were now dispensing medicines at a loss or without knowing whether or not they would be reimbursed at full cost. Should this continue, we were told there would be impacts on patient safety and access to medicines with as many as 87 per cent of contractors surveyed saying they were “very worried about their own business.” Several wholesalers have written to the Department to warn that the supply of medicines will grind to a halt because of pharmacies’ poor credit worthiness.
168.In February 2015, a Cost of Service Investigation (CoSI) of community pharmacy services was commissioned by the Department of Health. It examined the cost of providing services commissioned by the HSCB and other non-commissioned services during the period 2011–12. The investigation found that the cost of community pharmacy services came to a total of £130–136 million per annum.
169.In November 2018 the Department announced an additional £11.1 million of funding for community pharmacy. This included:
This package was in addition to a financial envelope of £104 million per annum for 2018–19 and 2019–20 to cover the delivery of community pharmacy services within contractual arrangements.
170.Before the £11.1 million package was announced, we heard that the network was facing at least a £20 million deficit in addition to a prolonged period of underfunding. The Chair of Community Pharmacy NI described the package of £11.1 million as a “sticking plaster approach” and that “rather than increasing the funding proposals that were under discussion during the summer the Department has responded by confirming a reduced level of funding.”
171.When questioned by this Committee on the financial pressures facing community pharmacy, the Chief Medical Officer told us:
There is no doubt that [ … ] there has been significant fluctuation in that profit on drugs because of costs of drugs. That has created some very significant financial challenges for community pharmacy.
With respect to the discrepancy between the findings of the Cost of Service Investigation and the levels of funding provided to community pharmacy by the Department, we were told that the CoSI “was never designed to determine what the financial envelope was like, but to inform it along with other inputs.” When pressed on this issue, the Chief Medical Officer told us that:
The Department faces significant financial constraints and many priorities across a number of budgetary areas. [ … ] We do not have the luxury of spending money that we do not have.
172.The Permanent Secretary at the Department of Health told the Committee that he considered community pharmacy to be “a fantastic resource for the community and for the health and social care system” and “of fundamental importance.” We were told that dialogue was ongoing between the Department and the community pharmacy network and that an agreement was “nearly there.” The Permanent Secretary went on to remark: “there is a lot of untapped potential in community pharmacy. We could better utilise it.”
173.Community pharmacies are a valuable healthcare resource and highly rated by the communities they serve—including some of the most deprived and rural communities in Northern Ireland—and uniquely placed to play a proactive role in the prevention and management of long-term conditions, promote wellbeing, deliver community-based healthcare and reduce pressures on General Practice. While securing a GP appointment may take days and sometimes weeks for many, community pharmacies are not appointment-led and able to provide a uniquely accessible service. Yet many are struggling to survive in the face of prolonged underfunding. The Committee recommends that the Department agree a sustainable funding package for community pharmacy based on the findings of its own Cost of Service Investigation and implement a Drug Tariff based on Northern Ireland’s unique set of circumstances.
364 Community Pharmacy NI, , November 2016, page 4
365 Ibid., pp. 5–6
366 Ibid., page 7
367 Ibid., page 8
369 Ibid., page 9
370 Ibid., page 11
371 HSC Business Services Organisation, , August 2019, page 33
372 Ibid., page 37
373 Ibid., page 36
374 Department of Health, , page 34
375 Millward Brown Ulster, , December 2016, page 6
377 Ibid., page 34
378 Ibid., page 38
379 Ibid., page 39
381 HSC Business Services Organisation, , August 2019, page 43
382 HSC Business Services Organisation, Family Practitioner Services Statistics for Northern Ireland 2018/19 (Revised Edition), , August 2019
384 Community Pharmacy NI ()
386 Department of Health, , 13 January 2017
387 Community Pharmacy NI ()
395 Chemist and Druggist, , 12 November 2018
396 PricewaterhouseCoopers LLP, , May 2017, page 5
397 Department of Health, , 16 November 2018
399 Community Pharmacy NI ()
400 Pharmacy Business, , 21 November 2018
Published: 2 November 2019