From Making Medicines to Optimising...

The 2013 UCL School of Pharmacy Lecture

From Making Medicines to Optimising Health

Sue SharpeChief Executive, the Pharmaceutical Services Negotiating Committee

An eighth century Baghdad apothecary shop (about 754 AD)An eighth century Baghdad apothecary shop (about 754 AD)

2 From Making Medicines to Optimising Health – Pharmacists in the 21st Century

IntroductionThis evening I want to explore what the community pharmacy network should be used for in the future, the obstacles that have limited progress to date, and how they can be addressed. Perhaps not surprisingly given my role in and commitment to the PSNC and to community pharmacy’s future, my proposals are predicated on a model that is based around retaining a strong network of accessible pharmacies. Of course there are alternative models that could be developed, that would require more radical reshaping of NHS provision and of patient and public behaviour. I believe we can reshape substantially, and with large savings in NHS resources and/or improvements in health outcomes, the contribution community pharmacy makes to caring for our population without damaging the established network or risking losing for what many people remains a familiar and trusted asset. The new NHS architecture may provide the framework and catalyst to making this achievable.

A radical examination is needed, of the actual and perceived value and limitations, the opportunities and barriers, and tonight my aim is to offer what I think is a realistic summation of the context for the reshaping of the community pharmacy proposition, and what it might look like.

I have been the Chief Executive of PSNC since 2001, before which I spent 10 years as the Director of Legal Services at the Royal Pharmaceutical Society, then of course the regulator as well as the professional body for pharmacy. So I have had more than 20 years’ experience of the recent development of pharmacists, over a period in which the profession has, in the hospital sector, seen a radical re-shaping of their role, and in the community sector has made some progress, but has encountered big obstacles, many of which remain to be surmounted.

Since the NHS Act of 1946 the Secretary of State for Health has been under a statutory duty to consult an organisation representative of community pharmacies when determining matters, principally funding, for the NHS community pharmacy service, and that is the origin of PSNC. We are funded by NHS pharmacy contractors, and work on their behalf.

The role of community pharmacy has changed radically since 1948, and with it the skills needed of pharmacists. The ownership structure of pharmacies has also changed radically in the last 25 years, with supermarkets entering the market, the growth and consolidation of large chains, the corresponding reduction in independently owned pharmacies and, most recently, the growth in GP owned businesses. And with other changes in consumer retail activity, the importance of the NHS and NHS revenues to pharmacy has changed quite fundamentally since the beginning of the NHS. This all provides context for the immediate future.

The pharmacist – recent historyIn 1948 most practising pharmacists had learnt their craft through a combination of apprenticeship and college training, at the conclusion of which they sat the Pharmaceutical Society’s Pharmaceutical Chemist examination. Major components of that craft were treating symptoms, and the compounding of medication prescribed for patients by its active ingredients, or chemists’ nostrums – the pharmacy’s own formulations, including cough mixtures and indigestion remedies. The apprentice learnt how to prepare not just pills and powders, but suppositories, cachous, poultices, liniments and embrocation. Other than controls on poisons, there was no prescribing restriction until the 70s on most ingredients. And of course, there were far fewer of them. After I joined the RPS in 1991, the solicitor who handled our disciplinary cases discovered that his favourite cough medicine, a chemist’s nostrum, contained an opiate so was illegal. He stocked up before we advised the pharmacist he needed to change his formulation.

The traditional pharmacy – the Chemist + Druggist of old – handled chemicals and noxious substances. He had a range of them, with which he helped his customers clean drains and kill rats, and cats, as well as providing chemicals to develop photographs as well, of course, as treating ailments.

From the 1930s the shift towards qualification by degree began to take place, although this was for a minority until well into the 1960s. The student completed a three year course followed by a one-year pre-registration training period, with the pre-reg examination being introduced in the 1990s.

So there had been a distinct change, from learning ‘on the job’, to learning in an academic environment, with practical training only at the end of the degree. That may have contributed to what I think was a problem with pharmacy education in the last few decades of the twentieth century – three years study overwhelmingly devoted to pharmaceutical science, leading to a degree approved by the Pharmaceutical Society. We trained scientists, not a profession with the interpersonal and other skills needed to communicate effectively with and understand the abilities and needs of patients and the public.

The importance of this to the role of pharmacy at the beginning of the twenty first century, was immense. In 2005 we introduced the Medicines Use Review into the national community pharmacy contractual framework, and feedback from pharmacy owners and from local pharmaceutical committees seeking to support adoption of the service, consistently reported that the greatest barrier to service delivery was pharmacists’ lack of confidence. A profession trained in science, and paid to dispense safely and accurately, felt itself ill-prepared for this structured communication with patients. This is, of course, a massive generalisation. Many pharmacists were good communicators and by no means all squirreled away in the dispensary, popping out into the pharmacy only when specifically asked for. But large numbers did.

And this had been their practical training and experience. In the latter half of the last century the pharmaceutical industry made massive strides in treating disease. In the 1960s the Thalidomide tragedy led to introduction of an authorisation regime for medicines based on clinical trials, and the pharmacist dispensed increasingly large volumes of an ever-widening range of licensed medicines, testament to the success of the manufacturing industry. The role of community pharmacy for the NHS was managing the procurement, stock, preparation, issue and billing of medication. Learning this, together with the complexities of the NHS requirements for endorsing and submission of prescription forms for pricing, formed the backbone of the pre-registration practical training. That is what the NHS paid pharmacy to do, so that is what the pharmacist had to learn to do. Pharmacists would give advice if asked, although frequently

The 2013 UCL School of Pharmacy annual lecture

Pharmacists in the early years of the NHS

From Making Medicines to Optimising Health – Pharmacists in the 21st Century 3

this was done by counter assistants, with sales of P medicines by assistants, under the laughable systems for supervision of the pharmacist manifested by nodding when the bell rang.

The universities have addressed the undergraduate skills in their courses in recent years, and there are proposals to integrate practical experience throughout the undergraduate programme. This is perhaps a great leap backwards. But if it ensures that pharmacists have the confidence and skills to adopt a role that is primarily about communicating effectively with the public and supporting them to be healthy, then it is a leap in the right direction.

There may be an element of rose-tinted spectacles about the pre-WW11 chemist, looking after the general health of his customers, filtering out the cases where advice was needed from a doctor and caring directly for those too poor to access medical help. But it is certainly the case that with free access to GPs from 1948, incentives to talk to the pharmacist first were lost. And GPs were happy to take on the role of the demi-god, and played a major role in creating the dependency culture that Sir Derek Wanless identified so clearly at the beginning of the century. I know about the demi-god: my mother was a GP who qualified in 1948, and spent her whole career as one.

When the NHS was established it was created around institutions. General Practice and hospitals formed the two principal pillars of the service, and that remains the case today. The GP was, as local demi-god, the family counsellor as well as the authority for sick days off work and entitlement to allowances and benefits, and as well as being responsible for diagnosis and treatment of illnesses. I remember my mother also acted as a Police surgeon, called to assess alleged victims of rape or other violence.

65 years on general practice remains overburdened with the multiplicity of roles it still has to perform. The GP is still the gatekeeper to much of the Health and Welfare system, and we have not found ways to allow them to use enough of their time in applying their clinical skills. This is not rational, and it does not meet our need to support people having an active engagement with their own health. This – the fully engaged scenario in the Wanless Report – must be an aspiration, not only to help the NHS meet demands on its resources. But also in addressing health inequalities. We need people to take an active interest and role in keeping healthy.

GPs are fully employed dealing with ill-health and the administration that surrounds it. We urgently need a new, third pillar, and the community pharmacy network, in my view, is the foundation of that pillar. Pharmacies must become the health place, which people use to keep healthy, avoid disease and risk factors, deal with minor episodes. They do so as part of a health system that is underpinned by communication and team-working, in which people are nudged towards using the right level of resource for their own needs. This cannot be a system rooted in traditional roles established long before developments in medical technology, communications, and treatments.

The DoldrumsBack to the post- Thalidomide years. A number of elements came together to create the pharmacy doldrums: free access to GPs; licensed medicines and the loss of compounding; academic training programmes; and growth in NHS dispensing volumes. When I first joined the RPS in 1991 that over- used and extremely irritating phrase “Pharmacy at the crossroads” was much bandied about – it still is today. The truth was that community pharmacy was in the doldrums. And only with the changes to the contractual framework in 2005 did we begin to pick up a breeze.

Pharmacy as a business had not been troubled by the shift away from the craft. Like many businesses it had ups and downs. But generally, until recently it was stable, particularly after entry control was introduced in 1987.

Community pharmacy NHS income grew steadily in the 50s, 60s and 70s, by when it accounted for around 50% of total pharmacy turnover for the average pharmacy. In the 1990s it was around 70%; today more than 85%. Consumers moved away from local shops, including pharmacies, for their everyday purchases. First toiletries, then baby. When retail price controls on medicines were abandoned, manufacturers of OTC products decided to treat them like other consumables and licensed general sales versions of Pharmacy only medicines. So they too moved to be part of the consumables shop, subject to price promotions like other goods. Finally, with the advent of digital photography, the old link of Developing and Printing to the chemist largely disappeared

Volumes of dispensing increased, compensating for the loss of other income. In the last 10 years alone dispensing volumes in England have increased by 56%, from 566m items in 2002-3, to 885m in 2011-12. The community pharmacy today is an NHS business, entirely dependent for survival on NHS income. Funding


National Health Service Act 1946

S1(1) • It shall be the duty of the Minister of Health … to

promote the establishment … of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention diagnosis and treatment of illness and for that purpose to provide or secure the effective provision of services …


The Third Pillar


NHS statistics - England

Year 2002-3 2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10

2010-11

2011-12

P’cies 9748 9759 9736 9782 10133 10291 10475 10691 10951 11236

Items (m)

566.3 596.5 623.2 659 688.4 725.8 771.5 813.3 850.7 885

Items/Pcy

59530 62691 65854 68808 70121 72818 75903 78458 80100 81030


is determined by dispensing volumes, creating powerful drivers for pharmacy businesses to concentrate on being efficient dispensing machines. The Scottish Chief Pharmacist has observed that dispensing is pharmacy’s sacred cow; and it is on its way to the abattoir.

The period from 2005 to date has seen a massive growth in pharmacy numbers in England: from 9,748 to 11,256 in 11-12. This was caused by an ill-advised policy change by the last government, where the advocates of service planning had to cede some ground to the proponents of deregulation. The new openings have done little to increase accessibility, clustering in locations already well served, close to, sometimes in, a GP practice.

The current core of the recognised role of community pharmacy – supply of medication, predominantly for long term conditions – coupled with this apparent attractiveness of pharmacy as a business - might make some think it is a candidate for NHS cost-cutting. The relaxation of pharmacist supervision requirements, together with automation, and rationalisation of pharmacy numbers, could be seen as ways to achieve savings. Pharmacy owners take the risk of business failure, and changing funding flows to rationalise and shrink the market could look like a low cost option for government politicians/bureaucrats in search of savings.

Community pharmacy is, so far as I can see, unique among NHS providers in not documenting huge swathes of its activity. As a consequence the present and future social value of the network has not been captured and evaluated. This undoubtedly makes it easier for commissioners to contemplate radical changes in the network. They have no basis on which to consider the impact on demand for GP consultations, recourse to NHS telephone helplines or to A+E associated with a loss of accessibility. Still less do we have a robust business proposition to support developing pharmacy as the third pillar of our health care system. We in pharmacy need to address this as a matter of urgency.

The period of austerity and implications for NHS fundingGP-led commissioning is only a few weeks away now, and CCGs are addressing how to manage growing demand and diminishing resources.

The NHS has trained people to look to general practice for all their health care, and GPs have, in between their efforts to manage demand in various ways which do not always improve users’ experience, sought to meet their needs, facing increased workloads and pressure on resources in recent years. Unless we change this – and it cannot be done by pharmacy alone – and adopt community pharmacy as a third pillar - the system may crack under the strain.

A report by the Nuffield Trust published in December (A Decade of Austerity) estimated that unless health funding could increase beyond inflation the NHS is set to face a funding gap, by 2021/2 of around £50bn. Improved productivity of 4% per annum across the NHS reduces the deficit by around 40%. But that is a massive demand, and we have recently seen the response of GPs to a proposed funding settlement for next year demanding 4% ‘efficiencies’. Community pharmacy negotiations – not yet completed for 2012-13 - demand the same level.

The Nuffield report is not optimistic. The chief economist at the Nuffield Trust, Anita Charlesworth, is quoted as saying: ‘There are no easy options for health beyond the current Spending Review. Without unprecedented, sustained increases in productivity, funding for health in England will need to increase in real terms after 2014/15 to avoid cuts to the service or a fall in the quality of care patients receive. The pressures from demography, illness and increasing costs will remain’.

A recent IPSOS MORI poll is quoted in the December 2012 Nuffield report. Almost 80% of those surveyed wanted public spending on some services to be protected, even if it meant bigger rises in taxation or deeper cuts elsewhere. And top of the list for funding protection is the NHS, with care for the elderly at number 3, after schools, but before the police and social services. 48% said they would most like to see increased taxes to maintain the level of spending. We are all worried about our health, and want the NHS to be capable of providing care when we need it. In time to come we may find that social care is also vital.

Some commentators may question the precise figures in the Nuffield report, and point to the relative protection enjoyed by health as opposed to social care. But few if any would deny that the welfare services as a whole will be under pressure in years to come.

So no wonder Sir David Nicholson, and the government are looking to increased productivity. But the problem of the need for increased productivity is finding solutions. The solutions to achieving better productivity- are inevitably multi-faceted, but effective use of the community pharmacy network can be a substantial part of them.

Pharmacy – the third PillarPSNC is the body recognised by the Secretary of State for Health as representing NHS ‘chemists’. So it is our job to ensure that the NHS uses this part of the NHS estate effectively, and of course funds it properly. PSNC must address NHS policy objectives and develop service propositions that support NHS priorities, and are manageable for community pharmacy and primary care.

We work to implement sound proposals. Many innovators are found in practice – the community pharmacists that lead in offering and developing services – and in universities. The background to the




MUR service traces to Gill Hawksworth and Professor Clare Mackie, both former pharmacy proprietors; the NMS to research funded by the Department of Health and undertaken by Professor Nick Barber and colleagues, working with Moss Pharmacy.

In the 2008 Pharmacy White Paper : Pharmacy In England, the Department of Health identified a range of ways in which pharmacists could be used in the future, many of which can be delivered, and reach more people, in the community pharmacy setting.

The third pillar has the current roles provided by community pharmacy as its foundation. But it will be very different from the pharmacy today.

PSNC has recognised for many years that the sector’s dependence on NHS revenues, and the centrality of the supply function coupled with pressures on NHS funding and changes in consumer behaviour, combine to make it necessary to redefine the community pharmacy offer. The 2005 Community Pharmacy Contractual Framework signalled the introduction of the four key areas: medicines optimisation; support for self-care; public health, and signposting – helping ensure people were helped to find services and support relevant to their individual needs.

Yet contrary to the objectives agreed in 2005 there was little development of the services in the following years.

There is a fundamental shift we need to achieve. It is changing the perceptions and habits that, perhaps unwittingly, the NHS has inculcated over the decades since 1948. General Practice and Pharmacy must commit to this shift, but the NHS and government must also work to make it happen, and drive the change in behaviour by our communities. Pharmacy can do it alone.

I now want to explain what this third pillar might comprise, and how it contributes to care and productivity for the NHS.

Advice on symptoms and treatment for ‘minor’ ailmentsThis is claiming back the traditional role of course. In many areas of the country PCTs have commissioned minor ailments services for varying ranges of conditions so it is not new. But nor is NHS care of minor ailments through pharmacies available consistently, indeed it is extremely patchy, and so does almost nothing to change consumer behaviours.

It is a massive waste of NHS resource to use general practice for easily diagnosed, common and easily treatable conditions, and it is no longer affordable.

In 2008 the PAGB, which represents manufacturers of non- prescription medicines, and PSNC worked together to make a case for transferring the care of minor ailments away from NHS GP services to community pharmacy. The list of minor ailments was derived from GPs.

IMS data showed that over 50m GP consultations a year, 18% of all GP consultations, were for minor ailments alone, costing £1.5bn a year in GP time. In the report we advocated a partnership approach that would release at least an hour a day for every GP.

The report noted the extent to which many people already self-care for minor ailments, but a MORI survey in 2005 showed that people’s main source of information on health is their doctor. When they decided to seek advice across a range of ailments, around 80% went to the GP practice, only 16% to pharmacy.

This is an obvious field for increasing productivity. The political dangers of meddling with free access to NHS services are a huge barrier to the perhaps obvious step of making pharmacist- supported self care the only option for minor ailments. Pharmacy minor ailments schemes offer a substantially cheaper means of providing NHS care for a large number of problems than GP care, so can offer the service without the political dynamite associated with limiting free treatment. Interestingly the MORI study, and other research into how people deal with minor ailments, did not find a strong correlation between income or social grade and behaviour – self-care or recourse to professional advice. Perceptions and habit seem to be the driving forces, and they can, and must be changed.

Pharmacy needs to adapt to offer this: we must be able, not just to deal with ‘walk-ins’, but also to offer advice and support by telephone and internet to respond to changing consumer behaviour. If we do not, others will fill this role.


The 2008 White Paper


PAGB/PSNC Minor Ailments Report 2008

…a significant opportunity for the NHS to use the skills and accessibility of community pharmacists to achieve a substantial increase in capacity… shifting care from the GP to the community pharmacy and to self care…


The Third Pillar


Medicines optimisationWe have managed, working with the government and the NHS, to lay some of the foundations that can expand the role pharmacies play in dealing with long term conditions. I have already mentioned the lack of confidence of the pharmacist workforce when the MUR service was introduced almost 8 years ago. That was matched by patients’ surprise when the reviews were offered. Pharmacy had played a large part in shaping peoples’ perceptions, that pharmacists had no role to play beyond dispensing medicines for long term conditions. When we began to offer the reviews, many patients and GPs saw this as a radical change. That is not something to be proud of.

The patient response to the review, from numbers of surveys conducted over the years, was overwhelmingly very positive. Although we have in some important ways trained our population to be the largely passive recipients of care determined by the GP, they had an appetite for information about the medication they were prescribed, and an interest in discussing their medication-taking practice and experience of use of the medicine in the less daunting and more informal environment of the pharmacy. Where a pharmacist communicated effectively with local GPs and agreed target patient groups, the value was accepted by general practice.

The role of the MUR in helping people understand their medication and its effects is an important contributor to the goal of having people fully engaged with their own health – the Wanless objective.

But lack of engagement by PCTs and GPs with the MUR service and the absence of effective targeting combined with lack of robust data capture and outcomes research has been problematic. The introduction last year of nationally agreed target groups and data capture requirements have started to help address these shortcomings. Research into respiratory MURs conducted on the South Coast provided strong evidence of improved control of patients’ conditions and the correlation between the service and reduced hospital admissions. 8-10% of hospital admissions are medicine- related. In future iterations of medicines optimisation services we should focus on the patient groups for which medication problems lead to expensive episodes, primarily hospitalisation. This is where the pharmacy service, properly used, can achieve real cost savings for the NHS, and convenient care for patients. Ensuring blood pressure levels are monitored, ensuring inhalers are being used properly, ensuring that, so far as possible, patients do not give up on medication regimes prematurely but get optimal health outcomes.

These groups – those with high hospitalisation rates - form the eligibility cohort for the New Medicine Service, and its’ introduction has been far smoother: through implementation of MURs pharmacists had gained the skills and confidence to offer the service, and we worked with GPs in advance, to get their support. Adoption levels, with 83% of pharmacies providing NMS services in year 1, have been outstanding.

The productivity gain for the NHS from these services will come from improved adherence, leading to reduced numbers of avoidable costs: GP consultations and hospital admissions. Early analysis of the NMS recorded using the PharmOutcomes platform shows significant gains in adherence, as indicated by the initial research that underpinned the development of the service.

There are a multiplicity of factors – social, psychological and others, which contribute to adherence problems, and further development of pharmacists’ communication skills will be needed if we are to make real improvements in productivity.

Figures for levels of non-adherence to medication regimes vary from 30-50%, but it is, I think, accepted that ineffective use of prescribed medication is a major problem. The IMS Institute for Healthcare Informatics report to the Ministers Summit held alongside the International Pharmaceutical Federation centennial congress last year, attempts to quantify the global cost of suboptimal use of medicines. They estimate that about 8% of total health expenditure or about $500bn (US) per year globally can be avoided with optimised use of medicines, which would prevent avoidable hospitalisations and improve medicines use. 57% of this is accounted for by non- adherence, and medication errors result in 9% of the avoidable costs.

Estimates such as these provide a glimpse of the size of the prize that can be won if the NHS can achieve better use of medicines. Sitting alongside the benefits that can be provided to each individual using a medicine, this provides a powerful incentive for the NHS and community pharmacy to take a greater role in optimising the use of medicines.

It will only happen with effective partnerships between community pharmacy and primary care: general practice, community nursing and social care. Growing recognition of the impossibility of managing future demands on our health system without radical change may act to catalyse those partnerships, if we are able to get engagement from the Department of Health, the Commissioning Board and CCGs. Building effective collaboration is vital.

The contribution pharmacies make to supporting independent living among older people or those with physical or mental disabilities fits with this model. A recent survey we undertook showed 93% of pharmacies will deliver medicines to people who have difficulty getting to a pharmacy; many will supply in compliance aids or provide reminder charts as well as other support. In the new public health commissioning structure there is greater opportunity than before to develop pharmacies’ work with social care. Today most carer organisations prohibit their staff from administering medicines. Pharmacies can help with reminders and support in monitoring patients, once more in partnership with social care, GPs and community nursing.

Experience of GP and community pharmacy contracting demonstrates the importance of getting the incentives right. The success of a community pharmacy today is dependent on three core factors: location and volume of prescription business, procurement skills, and services. In that order. We need to manage a re-ordering,


The two words 'information' and 'communication' are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through

Sidney.J.Harris


Our aim must be ensuring that the costs to the NHS are minimised to the greatest extent compatible with maximising patient outcomes, using the skills of doctors and pharmacists as effectively as possible


so the future success is determined by services for patients and partnership with primary care, accessibility and efficiency. This is not new. It underpinned the 2005 contract changes; it has been consistently reflected in government policy statements on pharmacy sine 1998, including the 2008 White Paper. And the report by AT Kearney published last year offered a compelling case for the service-led future.

In the 3rd Pillar model the community pharmacist supports the patient in self care. For long term conditions centrality of supply of medication gives way to taking responsibility for ensuring the patient uses medication appropriately and effectively. The GP will normally diagnose and initiate therapy, but the community pharmacist takes responsibility for ensuring the patient gets the best outcomes and identifies any changes to therapy that may be needed. The routine care of millions of patients shifts to the pharmacy, where it can be accessed more conveniently, and more cheaply, and patients have a range of providers from whom they can choose. The ‘bricks and mortar’ pharmacy service is supplemented by telephone, internet and where necessary domiciliary support.

IT to facilitate the creation and audit of clinical records in the pharmacy and to allow appropriate access to patient’s care records will be a critical enabler if this vision is to be achieved. Community pharmacy needs to stimulate the development of IT to support it to provide more effective services to patients and to allow it to communicate easily with patients and other healthcare professionals. The Government’s IT plans for healthcare commit to patient access to their GP records and the ability to make an appointment and order repeat prescriptions online. These changes and the use of open IT standards should allow inter-operability between systems, helping pharmacy and healthcare IT to move forward at a pace over the next few years.

The aim must be ensuring that the costs to the NHS are minimised to the greatest extent compatible with maximising patient outcomes, using the skills of doctors and pharmacists as effectively as possible. And this of course has implications for both pharmacy and general practice.

It is essential to identify and address barriers. These include accepting the perceptions of perverse incentives that undermine trust. So long as commissioners believe that pharmacies’ funding encourages them to dispense medicines that will not be used or that offer greater profit, there will be resistance to using pharmacists’ skills effectively. And GPs need to understand that patients do not always get all the information they need to be actively engaged in their health from GP consultations, so they can appreciate the contribution community pharmacy can make to effective and cost-efficient care.

Both professions must be committed to support this transfer of care, and in the case of community pharmacy this means radical

change: a complete change in perspective. But the developments in the last few years have prepared the sector for it. What might have been too radical to contemplate ten years ago is no longer a journey into the unknown. Helping our population care for themselves: from preventing disease, to managing acute episodes. For those living with disease – for increasingly long periods - ensuring they have the best possible outcomes from medication and helping to ensure that their care needs are fully met but at the lowest possible cost.

Healthy lifestylesI have spoken about pharmacy’s role in dealing with ill health, and that is the foundation of the pharmacist’s skill and value. There is also, to add to this, the use of the pharmacist and pharmacy team in prevention of avoidable disease, and promotion of healthy lifestyles. In 2002 Sir Derek Wanless captured the positive impact in reducing the rate of growth of health care costs of a population fully engaged in maintaining their own health. For many years successive governments have tried to tackle this, and with a limited measure of success.

A report into the outcomes of the 5 a day was published two weeks ago. The government’s former chief medical officer, Sir Liam Donaldson, says he thinks it has been partially successful so far: “The middle classes did listen, and the supermarkets listened and they tend to respond to the middle class consumer particularly. I think it’s been less successful in reaching the disadvantaged communities where those levels of fruit and vegetables were already low.”

Smoking cessation campaigns and services have had a significant measure of success, as the falling levels of smokers indicates. This chart also records the impact of changes in smoking habits on lung cancer rates.

But yet, according to newspaper reports at the New Year, we are now the second most obese country in the world, and the costs to the NHS associated with obesity-linked disease are growing at the same rate as our waistlines.

Community pharmacies have been providers of many public health services, including stop smoking, sexual health, and harm minimisation for drug misusers. More recently alcohol interventions and weight management have been piloted.

As ministers and new commissioners continue to seek effective ways of limiting the burden of lifestyle-related disease, there has been great interest in the role community pharmacies can play, particularly through the Healthy Living Pharmacy project.

The framework for healthy living pharmacies was developed and launched in Portsmouth in December 2009 and it led to quality and productivity improvements in community pharmacy with better


The Third Pillar



access to health and wellbeing services for the public. As well as committing to and promoting a healthy living ethos, one of the distinctive features of a HLP is having health trainer champions on site. HLP community pharmacies in Portsmouth exceeded the PCT’s stop smoking quit target by 138%, achieving 664 quits at 4 weeks for the year 2010/11. Evaluation results indicate that a person walking into an HLP in Portsmouth is twice as likely to set a quit date and give up compared with a person walking into a pharmacy which is not an HLP.

Twenty sites are currently being evaluated to see if the outcomes from Portsmouth can be replicated in different demographies and geographies. Today there are over 400 HLPs and 1000 healthy living champions in place.

Our 3rd Pillar is no longer just another part of the system concentrating only on cases of ill health. It is the health place – helping people live well, and avoid or limit risky behaviours. This is an important refocusing of the present role of the community pharmacy. Adoption of healthy lifestyles is critical to the affordability of our health care system in future. Developing the community pharmacy network, that provides extremely high levels of accessibility for the population, to be the health place, makes eminent sense. And there is no other candidate resource that the government can develop to support a fragile NHS as quickly, cheaply and effectively as community pharmacy.

Conclusion I am advocating a transformation of community pharmacy away from that of dispensary, and of course we must ensure that pharmacists have the skills they will need. The Schools of Pharmacy, and the General Pharmaceutical Council have the principal duty to ensure they equip future pharmacists to be comfortable in the new work and the new world around them. My impression is that recent changes in pharmacy schools’ curricula have increased the levels of behavioural and motivational skills, and that is an important element. I look forward to hearing what Duncan Craig and Mike Farrar have to say about this and related topics in a minute.

If community pharmacies increasingly take on roles associated with healthy living and social care, the pharmacist will be managing a team and will need to be comfortable with delegation. I think there are grounds for belief that frameworks for accountability and delegation still sit unhappily with the pharmacist and the profession must address this.

Community pharmacy must act to secure the transition from supply to health care, and I do not believe it can afford to delay in doing so. In the last few years we have established the foundations on which a future care-based service can be based. The pace of change, which has been slow, must accelerate, and as the new legislation is adopted, the opportunity for pharmacy is unparalleled.

I have noted some of the specific enablers of the 3rd Pillar. Routine capture of data; a multi-skilled team of people; adopting telephone and internet communications; driving the development of partnerships with GPs and other key people locally.

Although I have stressed that pharmacy cannot become the 3rd Pillar without the active commitment of the NHS + GPs, pharmacy owners and pharmacists must commit to the transformation. If they do not adapt, they go the way of all losers in the evolutionary process. Look at what Charles Darwin really said. We must offer the hand of cooperation to doctors/GPs, no longer the demi-gods of my childhood. We need to identify where we can help them manage the burdens they face, nudging them towards where they and the NHS can get real improvements in productivity through community pharmacy. I believe we have the answer. Getting there is the challenge for all of us.

END

The UCL School of Pharmacy New Year Lecture was in part funded via an unconditional grant from Pfizer Ltd. For further information about this event and other publication associated with it please call Professor David Taylor on 07970 139892 or email [email protected]


Health is the state about which medicine has nothing to say

WH Auden


The Third Pillar


It is not the strongest of the species that survives, nor the most intelligent. It is the one that is the most adaptable to change

Charles Darwin

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