You may have seen a recent article in a local paper about the shortage of pharmacies in West Berkshire. This was mainly drawn from a report by the National Pharmacy Association (NPA), which claimed that “many rural areas risk being left as ‘pharmacy deserts’ if current closure rates continue”. The seemingly eye-catching part about the story was that pharmacy provision per 100,000 people was worse in West Berkshire than in any of the other 143 upper-tier local authority areas in England.
On the face of it, this seems like a right shocker. However, there are several aspects worth looking at other than a crude headcount.
First, there’s not necessarily a connection between the number of pharmacies and the quality of service offered. Residents of Thatcham and Newbury will recall problems with the pharmacy provision last year. Some argued that more pharmacies were the answer. In the event, Boots managing to run its Newbury store more efficiently produced immediate positive results.
In Thatcham, the beneficial change was one of ownership: here, three pharmacies which were being indifferently run (by two by Lloyds and Boots) closed, the Lloyds ones being replaced by independents. Most seem to agree that these have been a great improvement.
The shift from a provision dominated by major chains (50+ stores) to more independent multiples (six to 49) and independents (fewer than five) is a trend that has been particularly noticeable in West Berkshire. Graham Jones, the long-time owner of the Lambourn Pharmacy, says that for about 20 years his was the only independent in the district. Such a heavy reliance on pharmacies whose future is at the mercy of decisions taken elsewhere is not ideal.
Lloyds, for instance, had over 1,400 stores in early 2020 but by the end of 2023 they’d all gone as the company slid into liquidation, mostly sold – including the two in Thatcham – “individually or in regional packages” to “independent pharmacy owners and local entrepreneurs”. Smaller is not always better, of course, though it seems to be in this case.
Nor does West Berkshire Council (WBC) appear overly concerned. Patrick Clark, WBC’s Portfolio Holder for Public Health, told us that the Council “keeps both the quality and quantity of pharmaceutical services under close review through its Pharmaceutical Needs Assessment (PNA). This identifies that ‘there is good access to essential, advanced and other NHS pharmaceutical services for West Berkshire’s residents with no gaps in the current and future provision of services identified.'” The next PNA is under construction and will be published in October 2025.
The quality of the service can also be measured by the roll-out of the Pharmacy First scheme from late 2023. The NHS claimed in January 2024 that 90% of community pharmacies in England will be offering “ground-breaking” service, though it’s less clear when this target will be hit. Others remain less convinced. In March 2024 The Pharmaceutical Journal quotes concerns that the scheme is “a step too far” unless staffing and financial issues are addressed; in the same month The Guardian quoted both the then head of the Commons health select committee and the Chair of the Association of Independent Multiple Pharmacies as claiming that the scheme may fail because of funding challenges.
Money – of course, money had to come up sooner or later. If there’s been a decline in the number of pharmacies over the last eight years – as the NPA and other sources such as Statistica suggest (though not to the same extent) – this is unsurprising considering the broken funding model. About 90% comes from the NHS but a 2024 report by Community Pharmacy England claims the lack of an inflationary uplift means this has declined by 30% since 2015.
Moreover, nearly 99% of pharmacies surveyed were either losing money or “only just profitable”. Pharmacies are not always able to recoup from the NHS the full costs of the medicines prescribed. There’s also a national shortage of qualified staff. All in all, it’s perhaps remarkable that the fall in pharmacy numbers has not been greater.
Strange as it might seem, this development in 2013 was anticipated, even welcomed, by NHS England’s chief pharmaceutical officer Keith Ridge. “There are too many pharmacies,” he said, responding to a recent report’s concerns about the “overcrowded” market which warned that many pharmacies could close unless the sector assumed an extended role in patient care. He felt a “survival of the fittest” approach could be healthy. His views have not become part of NHS orthodoxy: yet a decline in numbers has none the less happened.
WBC’s Patrick Clark also pointed out another aspect of the changing landscape, that “many customers are moving to online services”. However, he stressed he was aware that “locally available services remain important to many people and that pharmacists play a vital role in helping people manage their own health needs”.
All in all, pharmacies seem to be in a state of flux. Falling numbers is but one aspect. We also have established names leaving the market, challenges from virtual providers, staff shortages, a flawed funding model and the demands of extra responsibilities. And now, government reforms may push them into a more central role of national health-provision. What form might that take?
Writing in Pharmacy magazine in July 2024, Lambourn’s Graham Jones argued that we are “trapped in a psychology that doesn’t measure success or failure of the NHS on metrics of health, but on disease treatment and investment in this”. This, he suggests, holds the telescope the wrong way round. “Little investment goes into stopping patients falling into the river of ill health. It is spent on the expensive rescue missions further downstream.” The recent Darzi Report comes to a similar conclusion: “The NHS budget is not being spent where it should be,” point 13 of its summary reads, with “too great a share being spent in hospitals, too little in the community.”
A good example of this might be Boris Johnson’s eye-catching but unrealised promise to build 40 new hospitals. Investment in preventative healthcare, which many see as more beneficial, might take a generation to produce results and so is of comparatively little interest to governments running on a five-year spin cycle.
Non-governmental and international groups like Alphega (on which Graham Jones is the UK’s representative) are seeking to re-focus this approach. It will not surprise many to learn that several member countries, including the Netherlands and Germany, are doing better at this than are we.
For decades, UK pharmacies have been seen mainly as prescription factories. Ironically, the pandemic might have helped as they then became centres for vaccination and related healthcare advice. Pharmacy First is building on this heightened perception of their community value. Pharmacists are highly skilled and knowledgable and most now qualifying are independent prescribers. For decades, these talents have been under-utilised.
Whether or not this is set to change and whether national priorities will, to adapt Graham Jones’ image, move more investment further upstream, remains to be seen.
In pre-NHS days, high-street pharmacies were the only point of contact most had with health professionals, unless they could afford a doctor. In 1948, Bevan’s creation of the NHS changed that. Intentionally or not, pharmacists were relegated to a subsidiary role. The remedy for this might be a “back to the future” solution: much as the orthodoxy in the NHS might find it hard to accept that anything pre-1948 could possibly have performed better, or have had the capacity to do, than the current arrangements.
The new government has promised a reform of the NHS, as new governments so often do. This is a colossal task to attempt, still more to do with any success. The fractured model for funding community pharmacies and shaping their future role are central to these ambitions.
One thing that’s clear is that success in this area will be measured on more than a simple head-count. This is, however, the easiest way change can be described: so we’re probably stuck with it, both in the statements that are issued and the headlines written as a result.
Brian Quinn
