Pharmacies

My Lords, I add my thanks to the noble Lord, Lord Clement-Jones, for raising this debate. I want to concentrate on the problem of the relationships between GPs and community pharmacists, which have long been tense, but which can be changed for the better with the right policy incentives. From the 16th century until the mid-19th century, GPs and pharmacists were one and the same thing. They were both called apothecaries. Here I declare an interest as both a doctor and a member of the Worshipful Society of Apothecaries. For many years, the common enemy, as it were, were the physicians, who were very grand, expensive and out of reach of common folk. A landmark case brought by Sir William Rose in 1704 established the right of apothecaries to prescribe and dispense. The medical Acts of the mid-19th century created tighter controls over the education and regulation of those calling themselves doctors and separated them off, rather sadly in some ways, from those who ran pharmacies and chemist shops. It is relevant that many countries retain the principle of separation of the role of all dispensing from prescribing because of the obvious conflict of pecuniary interest of a doctor or pharmacist personally profiting from one prescription rather than another. We have never regarded that as a problem, particularly after the National Health Service Act came into effect in 1948, but there is no doubt that dispensing general practices are still perceived by the pharmacist to be a problem. The way that drugs are now paid for in general practice has reintroduced something of the conflict of interest again, and certainly conflicts between the two professions. Let me return to the basics for a moment. We must keep singing the praises of Britain's system of general medical and primary nursing care, complemented and supported by an easily accessible community pharmacy network. The noble Lord, Lord Selsdon, can find out exactly which pharmacies are open all the time on the front door of every pharmacist registered in this country. It is very easy to discover who is on duty, so you can find one. It is a national asset, but without a strong integrated system, the support of people with long-term conditions, who now make up the majority of patients, simply will not work effectively. But we are not really making the best use of pharmacists’ skills. We have done a lot in the past few years to encourage better use of them but we could do so much more to enable them to manage less serious acute illnesses and, of course, longer-term conditions. Community pharmacy has changed significantly. There is a trend towards a proportion of pharmacists being located in health centres and larger GP surgeries. There have also been initiatives to get surgeries into the larger pharmacies. Nevertheless, there is a physical separation and a social distance between most community pharmacists and GPs, reflected by their separate institutional arrangements associated with education, regulation and professional representation. There are no integrated financial incentives within the NHS to get people to work together. There is no doubt that people are using their pharmacists more for advice about episodes of illness. The latest Mintel consumer spending statistics survey showed that the market in over-the-counter pharmaceuticals has grown enormously, with sales expected to swell by a further 18 per cent in the next five years. Last year we spent a whopping £3 billion, an average of £59 per person, on over-the-counter medicines. The list of drugs for sale in pharmacies grows all the time. Some doctors are, of course, very wary of this trend. Professor Steve Field, chairman of the council of the Royal College of General Practitioners, really lit pharmacists’ blue touch paper when he commented recently that a pharmacist makes a profit selling over-the-counter drugs, whereas a GP gets no pecuniary benefit from giving you medicine. It was not true anyway, and especially not true of dispensing GPs, but both GPs and community pharmacists must respect each other as both run small businesses. This is the reality and they should respect each other for it. When it comes to buying drugs over the counter, you can almost hear the cheers from Richmond House. Prescriptions, even when they are paid for, cost the state money. It is not surprising that we would want to encourage more people to go to chemists’ shops. There is a problem, though. While pharmacists have expert knowledge about medicines, they do not have access to a patient’s medical history. Strangely, they are not regarded as part of the clinical service. As a result, care could become fragmented. If you have a recurrent problem, you may hope that a doctor or practice nurse will see a pattern and urge you to have it investigated, whereas in the self-medicating model, obviously, you could continue to get the symptoms and ignore the underlying causes. We must try to solve this problem by patient-agreed access to online medical records for pharmacists, with the patient’s consent. However, you can imagine that over many years this will, again, be an ongoing argument between GPs and pharmacists about who should have access. Theoretically, the new contracts that were introduced in 2004 have been very positive. These enabling, broader contracts brought the QOF system into general practice and made possible an enhanced role for pharmacists. They have undoubtedly introduced to pharmacy practice some enhanced services, but as the noble Lord, Lord Clement-Jones, said, these make up a very small proportion of the budget. I think £1 out of every £20 in the community pharmacy budget is spent on enhanced services. Two million medicine-use reviews will be conducted. As we heard from the noble Baroness, Lady Gale, these have been valuable in treating Parkinson’s disease and many other illnesses. Of the 2 million conducted, 500,000 were conducted by Boots the chemist, the brainchild of Jessie Boot. He was indeed one of us: Lord Boot. Boots is one of the larger providers of these enhanced services and has been most proactive in establishing them. However, GPs often do not value MURs. Indeed, they complain that they cannot even interpret the forms that pharmacists send them. Nevertheless, while they may need tweaking, they have made an important contribution. Another enhanced service would be, for example, the introduction of NHS health checks, aimed at vascular disease risk-assessment and reduction. So how do we foster this better joint working? Integrated remuneration systems on patient outcomes for monitoring chronic disease would be one way but I would start with increasing direct face-to-face contact that promotes greater mutual respect and professional trust through local practice forums. The only time a GP ever talks to a pharmacist is when the latter rings him up and says, "There’s been a mistake". We need to provide a forum where they can meet and gradually come to respect each other. This respect would be much more easily attained if pharmacy degrees were properly recognised as clinical qualifications and pharmacists were trained in broader clinical practice issues so that they become accepted as part of the clinical team. Doctors should be a little more understanding about the pharmacist who sells those wonderfully useless Seven Seas pills, snake-oil remedies and homeopathic humbug. They are nice little earners but they also enable the customer to choose his own care, and if he is paying for it and it will not poison him, why ever not? GPs and pharmacists need to respect each others’ skills more and trust each other more but we need to provide the clinical training for pharmacists that would ensure that they became a larger part of the clinical team.