Pharmacies

My Lords, the noble Lord, Lord Clement-Jones, in his excellent speech has largely relieved me of the worry of knowing how best to approach this multi-layered question. It is a truth universally acknowledged whenever this House debates pharmaceutical matters that pharmacists represent our most under-utilised national resource in the delivery of services to NHS patients. It is to the Government's credit that over the past few years they have taken steps to address this situation, in particular with the publication of the 2008 White Paper, Pharmacy in England: Building on Strengths. The word "strengths" was appropriate. My noble friend Lord Selsdon reminded us about the impressive level and extent of pharmacy training. We have in England around 10,000 pharmacies, and it is said that 96 per cent of the population is within 20 minutes of at least one of them, including those situated in deprived areas. As we have heard, community pharmacies have developed from being the main source of prescribed and over-the-counter medicines to providing a range of services designed to promote the health and well-being of the population. As the noble Lord mentioned, many pharmacies now offer vascular checks, heart disease management and prevention, diabetes screening and management, weight management programmes and smoking cessation services, and that is by no means an exhaustive list. For the individual, the advantage of going to a pharmacist for any of these services is that they are highly convenient and you do not usually have to make an appointment. For the NHS, the advantages are twofold: they are extremely cost-effective in comparison with the cost of delivering the same services via general practice; and potentially they also enable the coverage of such programmes to be extended to a larger population. Minor ailments are much better dealt with at pharmacist level because to the extent that patients can be encouraged to go to the pharmacist for advice about minor ailments, GPs are freed up to deal with more serious and complex conditions. It is estimated that every year GPs have to deal with more than 50 million minor ailment consultations, which represent about 20 per cent of their working time. That is not a cost effective use of the medical profession. In fact, the 2008 White Paper contained a lot that had already been said previously. The new community pharmacy contractual framework, which was introduced in the spring of 2005, was designed to encourage PCTs to use community pharmacy services more effectively. That did not work, as the Government have since admitted. In fact, it was worse than that, because when the framework was published, many pharmacists invested quite heavily in order to meet the opportunities they thought would be available, only then to be let down. So, what is holding us up? Why are we making such slow progress in the take-up of these new pharmacy services? To answer that, I think one has to look at what is happening with the commissioning process; and in particular what is happening, or not happening, with the world class commissioning programme. In March this year, the first panel reports about that programme were published. From those reports, the Company Chemists’ Association and the Association of Independent Multiple Pharmacies conducted an analysis of the 30 PCTs which were ranked as being "most competent" in the league table produced by the Health Service Journal. The purpose of the analysis was to determine how well or badly PCTs were commissioning pharmacy as a route to making themselves world class and to identify the contribution that pharmacy commissioning can make to PCTs’ performance as effective commissioners. What the analysis found was that effective commissioning of pharmacy was apparently not a priority during the first year of world class commissioning. Of the panel reports relating to the 30 "most competent" PCTs, only five mentioned the role of pharmacy. Many of the highest scoring PCTs did not demonstrate anywhere in their reports how they went about commissioning community pharmacy. On the other hand, some examples of best practice were given. I will mention a couple. Eastern and Coastal Kent was shown to be creating patient choice across all care settings, including the use of pharmacy in undertaking tasks normally done in hospitals. City and Hackney PCT is investing £1.2 million a year in a vascular check programme aimed at reducing inequalities on those who are screened and increasing the proportion of hypertensive patients on GP registers from 48 per cent to 80 per cent. These are simple, cost-effective ways for a PCT to reach world class commissioning standards, yet it would seem that the majority of PCTs simply have not hoisted this fact in. The average GP surgery consultation lasts 11.7 minutes and costs £32. The same 11.7-minute consultation in a pharmacy would cost just over half that. The potential savings to the budget are very great. They are particularly great when we look at the rollout of NHS health checks. Typically, a health check will consist of some questions about lifestyle combined with some standard physical tests. It is clear that unless pharmacists are used in the delivery of these checks, the idea will fail, because it is the hard-to-reach groups and the people who are not frequent users of healthcare for whom the checks are especially necessary. Can the Minister say what proportion of NHS health checks are being delivered by pharmacists? We know that some are: in Islington PCT, for example, community pharmacies are screening almost 1,000 people every six weeks. So, what ought we to do? One idea would be to incorporate NHS health checks into the community pharmacy contract as a standard feature. Another would be to require PCTs which are planning new vascular services, weight-management programmes or the like to factor in to their pharmaceutical needs assessments the contribution that community pharmacies are able to make to service delivery. There could be a greater emphasis on pharmacy in the next round of world class commissioning. But I feel in my bones that this will not be enough. After all, we have been here before in 2005 with the contractual framework for community pharmacy—a document which was laden with good intentions but which came to very little in practice. There are surely two things above all that need to happen if the aspirations we have all been talking about are to be met. The first is publicity. Patients and members of the public have got to know that these services are there to be had. Most people, I think, do not know. The White Paper contained a mention of publicity, but I am not sure how far this thought has been developed. It has to be tackled, and money and effort have to be spent on it. The second is that doctors and pharmacists, as we have heard, have to talk to each other. It is plainly in the interests of both that more people should access minor ailment services, vascular checks and weight-management advice outside the confines of the GP surgery. While initiatives from Richmond House are fine in their way, and indeed necessary, in the end it is up to pharmacists and doctors themselves to make it all happen. The noble Lord, Lord Clement-Jones, mentioned that a major hurdle to the extension of best practice in this area is pharmacists’ inability to access summary care records. That is a hurdle, but it should not be beyond the wit of man to devise protocols involving patient consent that would surmount it. Listening to the noble Baroness, Lady Murphy, I was led to wonder something that I doubted before, which is whether we need to think about incentives for co-operation. With any luck, some useful pointers for both doctors and the pharmacy profession, as well as for PCTs, will have emerged from this short debate. The subject is important and I hope that the Minister will be able to reassure us that it is high on her department’s agenda.